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Principles  of 

Surgical  Nursing 

A  Guide  to  Modern 
Surgical  Technic 

By 

Frederick  C.  Warnshuis,  M.  D.,  F.  A.  C.  S. 

Visiting  Surgeon,  Butterworth  Hospital,  Grand  Rapids,  Michigan 

Chief  Surgeon,  Pere  Marquette  Railway 

Secretary  of  the  Michigan  State  Medical  Society] 

Editor  of  the  Journal  Michigan  State  Medical  Society 

Member  of  the  Michigan  State  Board  of  Registration  in  Medicine 


With  255  Illustrations 


1X1  il'    A 


MAR  19  19 


Philadelphia  and  London 

W.    B.   Saunders  Company 

1918 


99 


7xO 


Copyright,  1918,  by  W.  B.  Saunders  Company 


PRINTED     IN     AMERICA 


TO    THE 

SUPERINTENDENTS  AND  GRADUATE  NURSES 

OF 
BUTTERWORTH  HOSPITAL 

THE   AUTHOR  UTILIZES   THIS   MEANS    OF   EXPRESSING 

HIS    APPRECIATION   FOR  THEIR   COOPERATIVE 

EFFORT  IN   HIS   WORK  IN   THAT 

INSTITUTION 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/principlesofsurgOOwarn 


PREFACE 

In  presenting  this  volume  to  the  nursing  and  hospital  world,  I  do  so 
with  some  trepidation.  I  am  not  so  fatuous  as  to  believe  I  am  imparting 
information  to  such  a  degree  as  will  enable  the  student  or  graduate  nurse 
to  gain  possession  of  all  that  is  requisite  for  a  nurse  engaged  in  surgical 
nursing.  The  foremost  thought  has  been  to  impart  essential  basic 
principles  that  will  enable  a  nurse  to  acquire  a  reliable  fundamental 
knowledge.  Possessed  of  facts  and  conversant  with  their  administrative 
principles,  the  attainment  of  perfection  will  be  readily  acquired  by  con- 
scientious work,  enlarged  experience,  collateral  reading,  and  study. 

With  but  one  or  two  exceptions  I  have  purposely  omitted  all  discus- 
sion of  the  literature  devoted  to  surgical  nursing.  The  subject  matter 
may  in  places  reflect  previous  expressions  and  opinions,  but  upon  the 
whole  the  text  is  based  upon  the  author's  personal  conclusions  and 
experiences,  and  the  views  that  have  been  acquired  by  perusal  of  the 
surgical  literature  which  has  appeared  from  time  to  time  in  current 
literature  and  proven  satisfactory  in  our  operative  work. 

Throughout  the  presentation  of  this  entire  subject  my  endeavor  has 
been  to  impart  facts  briefly  and  concisely,  so  that  the  instruction  would 
not  be  lost  in  a  maze  of  descriptive  and  lengthy  text.  Unusual,  obsolete, 
and  unimportant  methods  have  been  purposely  omitted  in  an  effort  to 
present  the  primary  and  pertinent  points.  The  sole  purpose  has  been 
to  describe  recognized  principles  of  technic,  accepted  plans  of  procedure 
and  treatment  as  they  exist  in  present-day  practice  of  surgery  and  surgical 
nursing.  To  advance  all  the  viewpoints  and  methods  of  surgeons  and 
instructors  of  nurses  would  be  impracticable.  Instead,  I  have  endeavored 
to  present  practical  methods  that  would  be  applicable  in  the  majority  of 
instances. 


12  PREFACE 

These  explanations  are  not  offered  as  apologies  or  to  refute  possible 
and  probably  justifiable  criticism.  They  are  recorded  that  the  reader 
may  understand  the  policy  and  plan  pursued. 

In  addition  to  the  text  I  have  resorted  to  illustrative  features  planned 
not  only  to  elucidate  the  text  but  to  serve  as  teaching  illustrations.  In 
their  preparation  studious  attention  has  been  given  to  their  detailed 
features. 

I  am  indebted  to  the  photographic  artist,  my  hospital  and  nurse 
friends,  and  to  my  editorial  assistants  for  their  valuable  aid  in  producing 
the  illustrations,  indexing,  correction  of  manuscript,  and  proof  reading. 

To  the  reader  and  student,  I  express  the  hope  that  this  volume  will 
serve  two  purposes :  First,  the  presentation  of  guiding  principles  of  surgical 
nursing  technic  of  today;  second,  to  stimulate  a  desire  for  further  knowl- 
edge of  the  subject,  thereby  inducing  the  nurse  to  devote  a  little  time  each 
day  to  research  and  study.  By  so  doing,  she  will  increase  her  ability  as 
a  necessary  and  potent  factor  in  the  surgical  clinic.  The  capable,  de- 
pendable surgical  nurse  receives  the  esteem,  commendation,  and  trust 
of  both  surgeon  and  patient. 

FREDERICK   C.   WARNSHUIS. 

Grand  Rapids,  Michigan, 
February,  1918. 


CONTENTS 


CHAPTER  I 

Page 

Foreword 17 

Surgical  Nursing  Outline 18 

CHAPTER  n 

Preparation  OF  THE  Room  AND  Its  Equipment  IN  A  Private  House 20 

Utensils .  24 

The  Final  Preparation  of  the  Room — "Setting  Up" 26 

The  Anesthetist's  Table 28 

Setting-Up 29 

Laparotomy  Kit 30 

Setting  Up  the  Supply  Table  of  Sterile  Goods , 30 

Solutions  and  Supplies 32 

Instrument  Table 33 

Dismantling  the  Room 36 

CHAPTER  III 

Methods  or  Hand  Sterilization 38 

Preparation  of  the  Hands — Scrubbing  Up 41 

CHAPTER  IV 

The  Preparation  oe  the  Patient 58 

General  or  Constitutional  Preparation 58 

Schedule  of  Preoperative  Procedure      63 

CHAPTER  V 

The  Preparation  of  the  Operative  Field 64 

Draping  of  the  Field 66 

Positions  on  the  Table 67 

CHAPTER  VI 

Duty  OF  the  Nurse  DURING  Operation 72 

Instruments 79 

Sutures  and  Needles 80 

Operative  Field 82 

Sponges  and  Packs 82 

Drains 84 

Dressings 87 

13 


14  CONTENTS 

CHAPTER  VII 

Page 

Post-Operative  Nursing  DURING  First  Twenty-four  Hours 91 

CHAPTER  VIII 

Post-Operative  Care  in  Normal  Convalescence  during  First  Twenty-eour  Hours  .    .  108 

Flatus no 

Cathartics in 

Catheterization 112 

Dressings 113 

Getting  Up 117 

CHAPTER  IX 

Post-Operative  Emergencies 120 

Shock  and  Hemorrhage 121 

Respiratory  Failure  or  Collapse 125 

Cardiac  Collapse 126 

Cardiac  Exhaustion  of  the  Second  Period 127 

Delayed  Hemorrhage .    .    .    , 128 

Ileus 129 

Acute  Gastric  Dilatation 129 

Acute  Anuria,  Uremia 130 

Peritonitis      130 

Post-Operative  Pneumonia , 131 

Exhaustion  and  Toxic  Singultus 131 

Persistent  Vomiting 131 

Phlebitis 133 

CHAPTER  X 

The  Process  or  Healing  and  Care  or  Wounds 136 

Healing  by  First  Intention 136 

Healing  by  Second  Intention 137 

Healing  by  Third  Intention ' 138 

Scars 138 

The  Care  of  Wounds 140 

Requirements  for  a  Dressing      143 

CHAPTER  XI 

Anesthesia 151 

Ether 152 

Chloroform '. 152 

Nitrous  Oxide  Gas 152 

Spinal  Anesthesia IS3 

Local  Anesthesia IS3 

CHAPTER  XII 

The  Nurse's  Chart  in  Surgical  Cases 156 

Temperature,  Pulse,  Respiration 157 


CONTENTS  15 

Page 

Bowel  and  Kidney  Excretions 158 

Nourishment 162 

The  Wound 162 

Miscellaneous  Details 163 

CHAPTER  XIII 

Formula 165 

Mustard  Plaster ; 165 

Flaxseed  Poultice 165 

Mustard  Poultice 165 

Tincture  of  lodin 165 

Turpentine  Stupes 165 

Chemical  Disinfectants  and  Antiseptics 165 

Methods  of  Disinfection 167 

Temperatures  of  Water  for  Baths,  Applications,  Douches,  and  Enemas 168 

Enemata 168 

CHAPTER  XIV 

Preparation  of  Surgical  Materials 171 

Making  Gauze  Dressings 173 

Strips      177 

CHAPTER  XV 

The  Surgeon's  Hospital  Kit 178 

Contents 180 

Uses 181 

CHAPTER  XVI 

The  Plaster-of-Paris  Splint     .    .    , 183 

CHAPTER  XVII 

Catheterization 198 

CHAPTER  XVIII 

Operation  for  Appendicitis 202 

Duties  of  Nurse  in  Preparation  and  during  Post-Operative  Period 202 

Nature  of  Disease 202 

Symptoms  of  Acute  Attack 203 

Complications 204 

Operative  Treatment 204 

Nursing  Care:  Preoperative 204 

Operation 207 

Post-Operative  Care 210 

What  to  Watch  for 211 

Complications 211 

Post-Operative  Nursing 214 


l6  ^  CONTENTS 

CHAPTER  XIX 

Page 

Hospital  Methods 217 

Surgeon's  Face  Mask 217 

The  Morning  Bath 219 

Bed-making 229 

The  Slush  Bath .  241 

Tub  Bath  in  Bed , 248 

Hypodermoclysis 252 

The  Technic  of  Thyroidectomy 262 


Index 269 


SURGICAL  NURSING 

CHAPTER  I 
FOREWORD 

The  recovery  of  a  patient  undergoing  an  operation  is  dependent  to 
a  large  extent  upon  the  technique  that  is  employed  and  observed  during 
the  entire  surgical  procedure.  It  is  by  reason  of  the  high  development  of 
present-day  surgical  technique  that  many  of  the  operations  now  under- 
taken result  in  a  low  mortality,  whereas,  the  same  operations  a  few  years 
ago  either  produced  a  high  mortality  or  were  not  attempted.  Further- 
more, many  procedures  are  now  possible  which  formerly  were  not  to  be 
•considered,  because  a  fatal  ending  invariably  resulted  by  reason  of 
infection. 

The  perfection  of  the  technique  is  dependent  upon  two  groups  of  in- 
dividuals— the  surgeon  and  his  assistants,  and  the  surgical  nurses.  The 
training  of  either  group  determines  the  character  of  the  surgical  procedure, 
causing  it  to  be  all  that  it  should  be  or  but  an  inferior  and  defective  sub- 
stitute. I  do  not  believe  that  it  is  necessary  to  advance  a  single  argument 
to  substantiate  the  statement  that  every  operation  should  reveal  a  rigid 
observance  of  modern  surgical  technique — the  chain  of  asepsis  should  be 
kept  intact  in  every  hnk.  Then,  and  then  only,  may  we  experience  the 
satisfaction  of  knowing,  no  matter  what  the  result,  that  our  duty  has  been 
faithfully  performed.  Then,  and  then  only,  may  we  hope  or  expect  to 
have  our  efforts  attended  with  end-results  that  justify  present-day 
statistics. 

The  constantly  changing  methods  of  operative  interference,  occa- 
sioned by  the  investigations,  studies,  and  experiments  of  surgeons,  carry 
with  them  new  refinements  and  the  development  of  modern  surgical 
principles  that  must  be  observed.  What  was  considered  essential  but  a 
2  17 


1 8  SURGICAL   NURSING 

few  months  ago,  may  today  be  classed  as  obsolete  and  cast  aside.  What  a 
nurse  was  taught  during  her  days  of  training,  in  many  instances,  may,  at 
present,  be  discarded.  In  view  of  this  fact,  it  is  imperative  that  a  nurse 
keep  abreast  of  the  times  and  put  forth  such  efforts  as  will  enable  her  to 
become  conversant  with  the  progress  being  made  in  surgical  technique, 
that  she  may  apply  the  approved  methods  in  her  daily  work.  It  will  be 
my  purpose  to  impart  an  understanding  and  a  working  knowledge  of  the 
guiding  principles  of  present-day  surgical  nursing.  While  I  realize  that, 
in  a  measure,  they  will  reflect  a  personal  viewpoint,  they  will  be  based  on 
present-day  surgical  procedures  that  have  proved  reliable  in  the  practice 
of  numerous  surgeons. 

In  the  end,  the  nurse  will,  I  trust,  have  gained  a  clear  insight  into  the 
progress  that  is  being  made  and  will  be  enabled  to  apply  any  new  knowl- 
edge she  may  gain  so  that,  no  matter  how  well  or  indifferently  the  surgeon 
may  perform  his  part,  she  will  have  the  personal  satisfaction  of  knowing 
that  her  duties  were  performed  in  accordance  with  accepted  principles. 

SURGICAL  NURSING  OUTLINE 

The  work  that  is  to  be  done  in  preparing  for  and  during  an  operation — 
which  duty  is  consigned  to  the  surgical  nurse — may  be  divided  into  the 
following  stages  or  steps : 

I.  The  Preparation  of  the  Operating  Room 

(a)  Selection  of  the  room.  (/)  Supplies. 

{b)  How  to  clean  it.  (g)  Instruments. 

(c)  Furniture  required.  (h)  Final  preparation. 

(d)  Utensils.  (i)  Setting  up. 

(e)  Solutions.  (7)  Dismantling  after  operation. 

2.  The  Preparation  and  Sterilization  of  the  Hands 

(a)   Consideration  of  wearing  apparel,  etc.        (d)  Precautions. 

(&)   Solutions  used  in  scrubbing.  (e)   Preparation  and  wearing  of  gloves. 

(c)    Methods  of  scrubbing.  (/)    Refinement  of  technique. 

3.  The  Preparation  of  the  Patient 

(a)   Physical  or  constitutional — general.  (b)  Local  or  operative  field — the  several  methods 

as  demanded  by  the  nature  of  the  operation. 


FOREWORD  19 

4.  The  Surgeon  and  His  Assistants 

(a)  Orders.  (e)  Service  entitled  to. 

(b)  Instruments.  (/)  Nurses'  duties  during  operative  work. 

(c)  Scrubbing.  (g)  Post-operative  nursing. 

(d)  Gowns  and  headpieces. 

5.  The  Operation 

(a)  Positions  of  patient  on  the  table.  (d)  Draping  the  patient. 

(b)  The  anesthetic.  (e)   Duties  during  the  steps  cf  the  operation. 

(c)  The  final  preparation  of  the  field. 

6.  Post-operative  Nursing 

A  consideration  of  the  duty  of  the  nurse  and  the  things  that  require  her  watchfulness  and  alertness. 
Surgical  chart. 

7.  Post-operative  Emergencies 

The  emergencies  that  may  arise  and  the  treatment  that  a  nurse  may  institute  before  the  surgeon's 
■  arrival. 

8.  The  Care  of  Operative  Wounds 
A  discussion  of  the  course  that  a  wound  may  take  and  how  it  may  be  best  treated. 

It  will  be  my  purpose  to  develop  these  steps  in  the  work  and  duty  of  a 
surgical  nurse  by  giving  essential  details  and  facts  and  avoiding  all  sem- 
blance of  verbosity.  Whenever  there  may  be  a  question  of  the  preferable 
method,  several  methods  will  be  given  in  order  that  the  nurse  may  be 
conversant  with  those  most  frequently  employed.  At  times,  I  shall 
advance  the  method  that  my  personal  inclination  may  fancy  or  approve. 
When  advisable,  however,  the  opinions  of  others  will  be  quoted.  In  all 
our  discussions  I  shall  endeavor  to  bear  in  mind  the  possible  surroundings 
that  may  exist  and  indicate  where  exceptions  may  or  must  be  made. 

With  this  specific  introduction,  we  dispense  with  further  generalities 
and  devote  ourselves  to  the  consideration  of  the  first  step. 


CHAPTER  II 

PREPARATION  OF  THE  ROOM  AND  ITS  EQUIPMENT  IN  A  PRIVATE  HOUSE 

Hospital  architects — these  speciaHsts  in  the  architect's  profession  have 
been  called  forth  by  the  development  of  our  modern  hospital — ^in  planning 
the  operating  rooms  for  a  new  and  modern  hospital  bear  in  mind,  while  so 
doing,  that  the  following  essentials  are  deemed  imperative  for  an  operat- 
ing room: 

1.  An  abundance  of  light;  absence  of  the  sun's  glare;  preferably,  a  northern  light. 

2.  A  room  so  located  as  to  be  distant  from  extraneous  or  distracting  noise  that  may  arise  from 
street  traffic,  adjacent  corridors,  elevators,  and  visitors. 

3.  An  abundant  supply  of  pure  air,  free  from  dust  and  admitted  without  drafts. 

As  these  essentials  are  deemed  important  in  institutional  work,  secur- 
ing like  surroundings  should  be  accomplished,  in  so  far  as  possible,  when- 
ever an  operation  is  planned  in  a  private  home  and  a  surgical  nurse  is 
sent  to  make  these  preparations.  Therefore,  in  selecting  a  room  in  a 
home,  the  nurse  must  not  be  unmindful  of  these  requirements.  A  careful 
inspection  of  the  residence  may  often  reveal  what,  at  first  glance,  might 
have  been  considered  impossible  for  the  satisfactory  arrangement  of 
an  operating  room. 

The  first  requirement  of  an  operation  in  a  private  home  is  a  room  that  is 
distant  from  the  noise  of  the  street  traffic  and  hidden  from  the  idle  gaze 
of  inquisitive  neighbors.  It  should  have  at  least  two,  and  preferably  three, 
windows  through  which  the  direct  sunlight  may  be  excluded  and  still  not 
deprive  the  room  of  sufficient  light  or  prevent  proper  ventilation.  Should 
the  operative  work  be  of  such  an  emergent  nature  as  to  necessitate  its 
performance  at  night,  then  the  natural  lighting  of  the  room  is  to  be  ignored 
and  attention  directed  toward  securing  the  best  artificial  lighting.  It  is 
unusual  to  secure  a  room  so  wired  as  to  give  a  sufficient  amount  of  arti- 
ficial light,  and  one's  chief  consideration  should  then  be  a  location  close  to 
several  sockets  to  which  the  light  cords  of  surgeon's  lamps  may  be  attached. 


PREPARATION  OF  THE  ROOM  AND  ITS  EQUIPMENT  IN  A  PRIVATE  HOUSE        2  I 

Most  surgeons  have  equipped  themselves  with  portable  lights  for  night 
work.  In  homes  that  are  without  modern  lighting  conveniences,  surgeon's 
lamps,  which  may  be  attached  to  the  storage  batteries  of  their  automobiles 
or  to  small  dry  cells,  will  undoubtedly  accompany  the  kit  that  is  sent  to  the 
patient's  home.  There  is  little  excuse  nowadays  for  requiring  people  to 
hold  lamps  and  candles  during  an  operation.  Such  practice  is  relegated  to 
the  past. 

In  selecting  a  room  a  nurse  should  always  bear  in  mind  what  the  re- 
quirements of  the  operation  will  be.  Many  steps  may  be  saved  if  the  room 
selected  is  located  near  a  bathroom  or  water  supply  and  a  range  or  stove. 
Impossible  as  it  often  is  to  find  a  room  that  possesses  all  these  desirable 
features,  one  must  attempt  to  select  one  that  has  at  least  a  good  light  and 
air  supply;  it  should  also  be  of  reasonable  size,  so  that  the  surgeon  and  his 
assistants  may  not  be  compelled  to  do  the  work  in  cramped  quarters. 
All  other  features  must  be  sacrificed  to  these  requirements. 

The  room  selected,  the  attention  of  the  nurse  will  then  be  directed  to 
its  preparation.  Its  extent  will  be  determined  by  the  time  that  remains 
at  her  disposal,  and  whether  or  not  the  operation  for  which  she  is  preparing 
is  one  of  an  emergent  nature.  If  twenty-four  hours  or  more  are  allotted 
her  for  this  preparation,  she  will  have  an  abundance  of  time  to  accomplish 
an  effective  technique. 

The  preparation  begins  with  superintending  the  removal  of  all  the 
furniture,  pictures,  drapes,  curtains,  and  rugs  or  carpets.  The  room  hav- 
ing thus  been  wholly  dismantled  by  members  of  the  family  or  servants,  the 
nurse  should  request  that  the  walls  and  mouldings  be  cleansed  from  any 
dust  that  may  have  accumulated  upon  or  behind  them,  and  that  the  wood- 
work, windows,  and  floors  be  washed  with  warm  water  and  soap.  In  brief 
the  room  is  to  be  given  a  most  thorough  cleaning.  The  foregoing  steps 
having  been  performed,  it  is  then  that  the  nurse  undertakes  the  direct  work 
of  final  preparation. 

In  order  that  this  final  preparation  may  be  methodically  and  effectively 
worked  out,  I  deem  it  wise  to  divide  the  procedure  into  seven  stages  or 
steps : 

First  Step. — The  glass  in  the  windows  is  to  be  covered  with  thin,  white 


22 


SURGICAL   NURSING 


tissue  paper  held  in  place  with  ordinary  flour  paste.  This  aids  greatly  in 
shutting  out  any  glaring  light  and  serves  also  to  obstruct  the  view  of  the 
room  from  without.  In  the  event  that  tissue  paper  is  not  available,  ordi- 
nary newspapers  may  be  used. 

Second  Step. — The  lower  third  or  half  of  the  window  casings  are  covered 


Pjq_  j_ — The  Arrangement  oe  a  Room  eoe.  Operation. — {Schematic.) 
A.  Dinino- table  arranged  for  use  as  an  operating  table.  B.  Small  table  for  anesthetist's  supplies. 
C.  Table  to  contain  unopened  'sterile  supplies.  D.  Table  with  sterile  supphes — sponges,  sutures, 
and  needles.  E.  Table  for  instruments.  F.  Board  resting  on  two  chairs  to  hold  scrub  basins,  soap, 
brushes,  solutions,  and  pitchers  of  sterile  water,  i.  Surgeon.  2.  Assistant.  3.  Anesthetist.  4. 
Clean  nurse. 


with  a  freshly  laundered  white  sheet,  maintained  in  place  by  tacks  so 
driven  as  not  to  mar  the  woodwork.  The  object  of  thus  draping  the  win- 
dow is  to  permit  the  lower  sash  to  be  partly  raised,  if  necessary,  during  the 
operation  and  yet  prevent  dust-laden  drafts  from  blowing  in  upon  the 
sterile  supphes,  instruments,  or  operative  field. 

Third  Step. — Clean  sheets  are  to  be  tacked  or  hung  around  the  walls  of 
the  room,  reaching  from  the  floor  to  a  height  of  four  or  five  feet  (Fig.  2). 


PREPARATION  OF  THE  ROOM  AND  ITS  EQUIPMENT  IN  A  PRR'ATE  HOUSE        23 

Fourth  Step. — The  floor  is  to  be  mopped  with  a  solution  of  bichlorid  of 
mercury  in  the  strength  of  i  in  500  or  with  lysol. 

Fifth  Step. — The  floor  is  to  be  covered  with  sheets,  tacked  in  a  suffi- 
cient number  of  places  to  hold  them  securely  in  place  and  prevent  anyone 
tripping.     These  sheets  are  temporarily  covered  with  a  loose  sheet  or 


Fig.  2. — Room  in  Private  House  Arranged  tor  Operation. 
The  walls  are  hung  with  sheets,  the  tables  are  draped  with  sterile  sheets,  the  window  prepared  by 
tissue  paper  pasted  over  and  a  sheet  tacked  over  the  lower  third,  the  floors  are  covered  with  sheets, 
and  the  table  is  padded  ready  for  a  folded  blanket  at  the  foot  and  the  rubber  sheeting  and  sterile 


newspapers  to  prevent  soiling  the  lower  sheet  while  the  remaining  supplies 
and  needed  furniture  are  being  carried  in. 

Sixth  Step. — Suitable  tables  will  be  required  for  the  patient,  the  instru- 
ments, and  the  supplies.  If  these  are  not  sent  by  the  surgeon  they  are  to 
be  selected  from  the  furniture  in  the  home.  After  they  have  been  thor- 
oughly cleaned,  they  are  wiped  off  with  a  cloth  wrung  out  frequently  in  a 


24  ■  SURGICAL   NURSING 

I  in  500  solution  of  bichlorid,  carried  into  the  room,  and  arranged  as 
shown  in  Fig.  i,  or  according  to  the  operating  surgeon's  preference. 

Seventh  Step. — The  windows  should  be  closed  and  locked,  and  the 
openings  between  the  sash  and  frame  sealed  with  ordinary  surgeon's  adhe- 
sive plaster.  A  sufficient  number  of  formaldehyde  fumigators  should 
be  placed  in  tin  pans  and  lighted,  the  door  closed  and  locked,  and  its  key- 
hole and  margins  sealed  with  adhesive  plaster,  thus  subjecting  the  room  to 
a  thorough  fumigation. 

The  room  may  then  be  considered  as  prepared,  and  no  one  should  be 
permitted  to  enter  it  until  the  nurse  undertakes  the  final  preparation  for 
the  actual  operative  work.  By  this  method  you  will  secure  as  ideal  an 
operating  room  as  is  possible  in  a  private  home.  True,  it  demands  a  vast 
amount  of  work,  but  this  should  not  be  begrudged  if  it  advances  the  safety 
of  the  patient  to  a  higher  degree.  We  admit  that  in  emergencies  it  will 
often  be  impossible  to  subject  a  room  to  such  a  thorough  preparation,  and 
necessity  will  compel  a  compromise.  In  this  event,  the  nurse  must  be 
competent  to  carry  out  the  essentials  in  so  far  as  the  time  at  her  disposal 
permits.  Reasonable  security  may  be  attained  if,  after  the  furniture  is 
removed,  the  floor  be  covered  with  sheets  moistened  in  a  solution  of 
bichlorid  of  mercury  of  i  in  500  strength.  The  lower  sash  of  the  windows 
should  be  covered  with  sheets  dampened  in  the  same  antiseptic  solution. 
Time  may  also  be  found  for  a  maid  to  dust  the  woodwork  with  a  bichlorid 
moistened  cloth.  Your  individual  tact  and  executive  ability  will  enable 
you  to  utilize  the  needed  safeguards  in  emergency  home  operations. 

With  the  completion  of  these  duties  the  nurse  has  still  more  work  to 
perform  before  the  preparation  of  the  room  is  complete.  These  duties  are 
to  be  performed  in  another  part  of  the  home  and  pertain  to  the  utensils  and 
water  supply  that  will  be  demanded  for  expeditious  operative  work. 

UTENSILS 

In  addition  to  the  surgical  suppHes,  instruments  and  lighting  apparatus, 
which  will  be  sent  by  the  surgeon  in  sterile  containers  from  the  hospital, 
certain  utensils  and  water  must  be  provided  in  a  manner  replete  with 
surgical  thoroughness.     These  consist  of : 


PREPARATION  OF  THE  ROOM  AND  ITS  EQUIPMENT  IN  A  PRIVATE  HOUSE        25 

Four  hand  basins,  granite  or  porcelain,  for  scrubbing. 
Two  hand  basins,  granite  or  porcelain,  for  hand  solutions. 
Three  pitchers  for  sterile  water  and  saline  solutions. 
Two  enamel  basins  for  sterile  table  for  alcohol  and  saline. 
Three  cups  or  glasses  for  alcohol,  iodin,  and  carbolic  acid. 
Ten  gallons  hot  sterile  water. 
Ten  gallons  cooled  sterile  water. 
One  foot  tub  for  soiled  sponges,  used  solutions,  etc. 

The  hand  basins,  in  fact  all  the  basins,  pitchers,  cups,  or  glasses,  are  to 
be  cleansed,  rinsed  off,  and  then  boiled  in  a  boiler  for  at  least  thirty 
minutes,  after  which  they  are  to  be  submerged  in  a  i  in  500  bichlorid 
solution  and  permitted  to  remain  there  until  needed.  A  suitable  storing 
container  for  the  bichlorid  solution  may  be  found  in  a  wooden  tub ;  do  not 
use  a  galvanized  tub  on  account  of  the  chemical  action  of  the  mercury. 
The  water  in  which  they  are  boiled  may  be  used  to  make  the  bichlorid 
solution.  They  may  also  be  left  in  their  original  boiler  and  extra  handling 
avoided. 

When  these  utensils  are  finally  needed,  they  are  taken  out  of  their  con- 
tainer by  means  of  a  sterile  forceps  and  thoroughly  rinsed  with  sterile 
water.  They  are  then  ready  for  use  but  must  be  handled  under  all  sterile 
precautions  to  prevent  rendering  them  unsterile. 

Sterile  Water. — Provision  should  always  be  made  for  an  abundance  of 
sterile  water.  It  is  secured  by  boiling  for  at  least  thirty  minutes.  It 
should  be  stored  in  sterile  pitchers  covered  with  sterile  towels.  Just 
preceding  and  during  the  operation  there  should  be  a  boiler  of  hot  sterile 
water  on  the  stove.  A  quantity  of  cool  sterile  water  should  be  held  in 
reserve. 

Saline  Solution. — The  following  method  of  preparing  the  saline  solu- 
tion, or  normal  saline,  is  in  general  use : 

1.  Thoroughly  clean  a  large  utensil  in  which  to  boil  the  solution  and  the 
pitcher  or  bottles  for  storing  the  solution. 

2.  Fill  this  utensil  nearly  full  of  water  and,  after  placing  the  cleaned 
pitcher  or  bottles  in  the  utensil,  cover,  and  boil  briskly  for  thirty  minutes. 

3.  While  these  are  boiling  add  two  small  teaspoons  of  table  salt  to  a 
quart  of  water  and  filter  the  mixture  through  filter  paper  or  absorbent 
cotton. 


26  SURGICAL   NURSING 

4.  Remove  the  pitcher  or  bottles  from  the  boiling  water,  leaving  them 
filled  with  the  sterile  water  in  which  they  were  boiled.  Pour  the  remaining 
water  out  of  the  utensil. 

5.  Pour  the  filtered  salt  solution  into  the  same  utensil,  cover,  and  boil 
for  thirty  minutes.  Then  add  enough  sterile  (boiled)  w^ater  to  supply  the 
quantity  lost  by  evaporation,  so  that  you  will  have  a  full  quart. 

6.  Pour  the  solution  into  the  sterile  pitcher  after  pouring  out  the  sterile 
water  it  contained;  cover  with  a  sterile  towel  tied  over  the  pitcher. 

7.  If  the  solution  is  to  be  kept  for  future  use  pour  it  into  the  bottles, 
after  emptying  the  boiled  water  out  of  them. 

8.  Cork  the  bottles  with  plugs  of  cotton  batting  (not  absorbent  cotton) 
that  have  been  sterilized  by  baking  until  brown. 

If  the  solution  is  not  to  be  used  the  day  it  is  sterilized,  sterilize  it 
twenty  minutes  for  three  consecutive  days.  This  "fractional  steriliza- 
tion" assures  destruction  of  bacteria  that  may  have  developed  from  spores 
not  killed  by  the  first  and  second  sterilization. 

The  faithful  performance  of  the  foregoing  tasks  will  witness  the  com- 
pletion of  the  first  half  of  the  preparation  of  the  room  on  the  day  before 
the  operation.  The  preparation  of  sterile  water  may  be  omitted  until  the 
morning  of  the  operation. 

THE  FINAL  PREPARATION  OF  THE  ROOM— "SETTING -UP" 

On  the  day  upon  which  the  operation  is  to  be  performed,  the  room,  pre- 
pared according  to  the  suggestions  laid  down,  should  be  thoroughly  aired 
for  a  sufficient  length  of  time  (four  to  six  hours)  to  remove  all  traces  of  the 
formaldehyde  fumes.  The  error  must  not  be  committed  whereby  an 
insufficient  amount  of  time  is  allotted  for  this  purpose.  It  is  extremely 
uncomfortable,  and  at  times  impossible,  to  work  in  a  room  whose  atmos- 
phere is  laden  with  the  irritating  fumes  of  formaldehyde.  Therefore,  allow 
time  for  their  complete  removal  by  sufficient  airing.  While  so  doing,  dust 
may  be  prevented  from  entering  through  the  windows  by  covering  the 
entire  window  frame  with  a  sheet  fastened  to  the  top  of  the  frame. 

The  room  having  been  thus  subjected  to  a  complete  airing,  and  the 
hour  for  the  operation  but  briefly  distant,  the  final  steps  of  preparing  the 


PREPARATION  OF  THE  ROOM  AND  ITS  EQUIPMENT  IN  A  PRIVATE  HOUSE        27 

room,  or  "setting-up,"  as  it  is  commonly  termed,  are  rapidly  executed  in  an 
orderly,  definite,  and  thorough  manner. 

The  woodwork  should  receive  a  final  dusting  with  a  cloth  dampened  in 
bichlorid.  The  tables  and  stands  are  to  be  gone  over  in  like  manner. 
The  temporary  sheet,  which  was  placed  over  the  permanent  sheet  tacked 
to  the  floor,  is  removed,  and  the  permanent  sheet  is  moistened  with  a  solu- 
tion of  bichlorid. 

The  operating  table  is  to  be  covered  with  a  clean  flannel  blanket  of 
sufiicient  thickness  to  be  comfortable.     Patients,  for  months  after,  vividly 


Fig.  3. — Two  Arrangements  of  Dining  Table  to  Secure  Trendelenburg  Position. 

In  both  instances  the  blanket,  rubber  sheeting,  and  clean  sheet  are  placed  over  the  inclined  boards 

or  chair  and  the  patient's  knees  so  fastened  as  to  prevent  sliding. 

recall  being  placed  upon  a  hard  and  uncomfortable  table.  This  unpleasant 
recollection  may  be  prevented  if  the  nurse  will  but  take  the  precaution  to 
secure  ample  padding  with  blankets.  Over  these  blankets  is  spread  rubber 
sheeting,  which  in  turn  must  be  covered  by  a  clean  sheet.  A  small  pfllow 
should  be  provided.  In  a  subsequent  chapter  I  shall  fully  describe  the 
several  positions  that  are  required  for  different  operations.  While  dis- 
cussing the  final  preparation  of  the  table,  however,  it  ma}^  be  well  to  men- 
tion briefly  one  or  two  methods  whereby  one  of  the  most  common  posi- 
tions— the  Trendelenburg — may  be  arranged. 

Trendelenburg  Position. — This  position  may  be  secured  by  placing  at 
the  foot  of  the  table  a  block  of  wood  of  sufficient  weight  and  thickness  to 
secure  the  desired  elevation  of  the  hips.  Over  or  on  this  block  there  are 
placed  two  leaves  of  the  table,  securely  fastened  as  illustrated  in  Fig.  3, 


SURGICAL   JNURSIKG 


and  the  padding,  rubber  sheeting,  and  sheet  should  be  placed  over  these 
inclined  table  leaves. 

The  position  may  also  be  secured  by  the  use  of  a  chair  turned  upside 
down  and  securely  bound  in  place.  A  Kelly  pad  is  placed  as  the  nature  and 
character  of  the  operation  will  indicate. 

THE  ANESTHETIST'S  TABLE 

The  anesthetist's  table  may  be  any  small  table  or  stand  and  is  placed  as 
indicated  in  Fig.  i.     On  it  should  be  arranged  the  following  articles: 


Four  cans,  quarter  pound,  anesthetic  ether. 

Bottle  chloroform,  four  ounces. 

Jar  or  tube  sterile  vaseline. 

Tongue  forceps. 

Mouth  gag. 

Package  sterile  gauze. 

Castor  oil,  one  ounce. 

Medicine  dropper. 


Hypodermic  syringe,   loaded  with    the  anes- 
thetist's preferred  stimulant. 
Hypodermic  syringe,  empty. 
Glass  sterile  water,  covered. 
Two  anesthetic  masks. 
Three  small  hand  towels  or  napkins. 
Vomitus  basin. 
Hypodermic  tablets. 


Fig.  4. — Anesthetist's  Table  of  Supplies. 
The  table  contains  the  following:  Cans  of  ether,  chloroform,  vaseline,  castor  oil,  medicine  dropper, 
hypodermic  syringes,  hypodermic  tablets,  glass  of  sterile  water,   vomitus  basin,  anesthetic  masks, 
towels,  package  of  gauze,  mouth  gag,  tongue  forceps. 

The  hypodermic  syringe  and  tablets  or  stimulants  are  to  be  furnished 
by  the  anesthetist.  It  is  incumbent  upon  the  nurse  to  attend  to  the  ar- 
rangement of  the  supplies  of  the  anesthetist's  table  aside  from  the  hypo- 
dermic syringes,  unless  she  is  instructed  otherwise. 


PREPARATION  OF  THE  ROOM  AND  ITS  EQUIPMENT  IN  A  PRIVATE  HOUSE        29 

The  tables  are  next  to  be  set  in  the  position  preferred  by  the  operator. 
The  table  or  board  intended  to  hold  the  basins  and  solutions  for  scrubbing 
up  are  arranged  last;  the  hand  brushes  and  solutions  are  placed  thereon 
and  covered  with  sterile  towels  until  ready  to  be  used  (Fig.  9). 

The  storage  containers  of  hot  and  cold  water  are  brought  in  and  placed 
in  an  out-of-the-way  corner,  but  they  should  not  be  inaccessible. 

The  "kit,"  containing  the  sterile  goods  received  from  the  hospital,  is 
unpacked  and  its  contents  arranged  upon  the  table  reserved  for  unopened 
supplies. 

Thus  is  the  room  prepared  and  arranged  in  a  definite  and  painstaking 
manner.  Up  to  this  point  all  the  work  has  been  done  by  the  nurse  with- 
out personal  sterilization.  To  complete  the  final  and  last  steps  of  prepara- 
tion, it  is  essential  that  the  nurse  now  "scrub  up,"  don  sterile  headpiece, 
gown,  and  gloves,  and  perform  the  final  and  last  work  of  preparation  with 
the  assistance  of  an  "unscrubbed  nurse,"  or  some  person  who  can  intelli- 
gently aid  her  in  the  last  details. 

The  most  approved  methods  of  hand  sterilization  and  robing  oneself  in 
a  sterile  gown  well  merit  detailed  consideration  and  discussion.  I  have 
deemed  it  of  sufficient  importance  to  devote  a  separate  chapter  to  this 
subject  alone.  However,  in  order  that  I  may  not  cause  a  break  in  the 
plan  of  preparing  for  an  operation,  our  discussion  will  continue  with  the 
supposition  that  the  "clean,"  "scrubbed,"  or  "sterile"  nurse  has  faith- 
fully prepared  herself  to  proceed  with  the  arrangement  of  the  supplies. 

SETTING-UP 

The  "clean,"  "sterile,"  or  "scrubbed"  nurse,  however  she  may  be 
designated,  properly  scrubbed,  gowned,  and  gloved,  from  now  on  has  the 
help  of  an  "unscrubbed"  nurse,  or  assistant,  who  aids  her  in  the  final 
"setting-up."  Thus,  the  clean  nurse  will  not  be  rendered  unclean  by 
coming  in  contact  with  unsterile  articles  or  containers. 

The  unpacking  of  the  sterile'goods  of  the  kit  is  next  to  be  undertaken. 
This  kit  may  be  a  general,  laparotomy,  appendectomy,  or  a  gynecological 
kit,  according  to  the  nature  of  the  operation.     A  laparotomy  kit  contains 


30 


SURGICAL   NURSING 


the  following  articles,  which  are  to  be  unpacked  and  piled  upon  the  table 
set  aside  for  holding  unpacked  sterile  goods: 


LAPAROTOMY  KIT 

Sterile  towels 3  packages,  i  dozen  each 

Sterile  sheets 4 

Sterile  laparotomy  sheet i 

Sterile  laparotomy  towel i 

Sterile  gowns 5 

Sterile  dressings. . ., 5  packages 

Sterile  powder  for  gloves 

Sterile  cotton 2  packages 

Sterile  sponges: 

12  long 2  packages 

12  square 2  packages 

24  long 3  packages 

Medicated  laparotomy 2  packages 

Vaginal 2  packages 

Sterile  appendectomy  strip i 

Sterile  abdominal  pads 2 

Sterile  perineal  pad i 

Sterile  applicators i  package 

Sterile  packing,  plain,  i-inch,  2-inch,  4-inch i  each 

Sterile  packing,  iodoform,  2-inch,  4-inch i  each 

Box  containing: 

Razor  Alcohol,  large  bottle 

Assorted  sizes  rubber  tubing  Green  soap 

Rubber  and  glass  catheters  Ether,  4  cans 

Douche  and  irrigating  points  Chloroform,  2  bottles,  2  ounces  each 

Safety  pins,  i  dozen  Sterile  vaselin 

Adhesive  straps,  2  sets  Small  chloroform  mask 

Catgut  Bandages,  2,  4,  and  6-inch,  2  each 

Silkworm  gut  6  Nail  brushes  and  orange-wood  sticks 

Pagenstecher  6  Face  masks 

Silk,  fine  and  heavy  i  Douche  bag 

Black  linen  i  Instrument  pan 

Carbolic  acid,  95  per  cent.  Hypodermoclysis  needle 

CarboUc  and  iodin  Surgeon's  suits 

Oil  of  cloves  6  Basins 

Lime  and  Soda  i  Kelly  pad 

Bichlorid  tablets  Instruments 

Collodion  Needles 

Tincture  of  iodin  Gloves 

Harrington's  solution  Drainage  Tubes 
Formaldehyd 

SETTING  UP  THE  SUPPLY  TABLE  OF  STERILE  GOODS 

The  unclean  nurse,  who  holds  herself  at  all  times  ready  to  comply  with 
the  requests  of  the  clean  nurse,  should  know,  or  be  instructed,  how  to  open 
the  containers  holding  the  sterile  goods  in  such  a  manner  as  not  to  con- 


PREPARATION  OF  THE  ROOM  AND  ITS  EQUIPMENT  IN  A  PRIVATE  HOUSE        3 1 

taminate  the  contents  and  yet  permit  the  clean  nurse  (Fig.  6)  to  remove 
the  contents  without  becoming  contaminated.     The  illustration  (Fig.  5) 
demonstrates  a  reliable  method. 

The  first  package  opened  should  contain  a  sterile  sheet,  which  is  used 


Fig.  s.— Method  of  Opening  Package  op  Sterile  Supplies  by  the  Unsteeile  Nurse. 
The  ends  of  the  package  have  been  unpinned  and  unfolded.     Grasping  the  sides  of  the  package, 
the  nurse,  by  a  quick  upward  movement  of  the  package,  throws  the  wrapping  open  without  touching 
the  contents. 


\^ 


j.^.-., 


J 


Fig.  6. — Sterile  Nurse  Removing  Sterilized  Supplies  from  Package  Previously  Opened  by 

Unsterile  Nurse. 

The  sterile  nurse  is  wearing  two  pairs  of  rubber  gloves.     The  cuffs  of  the  outer  pair  are  turned] 

back  so  that  they  may  be  removed  without  touching  the  surface  of  the  inner  gloves. 

to  cover  the  open  sterile  supplies  table  and  prevent  the  unsterilization  of 
the  articles  that  are  piled  thereon.  With  the  table  thus  protected,  place 
upon  it,  in  an  orderly  and  easily  accessible  arrangement,  the  following 
sterile  goods:  towels,  sponges,  packs,  dressings,  gowns,  packing,  drainage 
material,  gloves,  sutures,  needles,  needle  holders,  and  scissors.     Three 


32 


SURGICAL    NURSING 


sterile  basins  must  also  be  supplied  to  hold  sponges,  saline  solution,  and 
alcohol.  Small  cups  for  alcohol,  iodin,  carbolic  acid,  or  any  other  solution 
employed,  should  be  placed  also  upon  this  table. 

Tljis  table  is  the  nurse's  work  bench;  it  will  be  seen  from  the  importance 
of  the  supplies  thereon  that  the  arrangement  should  be  convenient  and 
ample  space  allotted,  so  that  when  called  upon,  the  work  of  the  nurse 
may  not  be  retarded  by  overcrowding  or  "cluttering  up"  of  this  table. 
The  arrangement  must,  of  necessity,  be  such  that  whatever  is  called  for 
can  be  found  instantly.  As  a  suggestion  for  convenience,  the  fol- 
lowing schematic  arrangement  will  be  found  very  satisfactory  in  actual 
work  (Fig.  7). 


Fig.  7. — Table  of  Sterile  Supplies. 
The  contents  of  this  table  are  as  follows:  Upper  row — Sterile  towels,  surgical  gowns,  dressings, 
packing,  drainage  tubes,  iodin  cup,  alcohol  cup,  carbolic  cup,  novocain  or  special  solution  in  bowl, 
dusting  powder.  Middle  row — Alcohol  basin  for  sutures,  tray  for  sutures,  soiled  sponge  basin, 
sponges,  gloves,  basin  for  normal  saline.  Lower  row — Threaded  needles,  suture  scissors,  needle  for- 
ceps, rubber  gloves,  reserve  supply  of  instruments. 

This  table  set  up,  its  contents  are  protected  with  sterile  towels  until  the 
operation  is  begun. 

SOLUTIONS  AND  SUPPLIES 

There  will  be  found  in  the  hospital  kit  supplied  by  the  surgeon  the 
solutions  and  supplies  listed  on  page  30.  They  are  mentioned  in  this 
chapter  in  order  that  the  nurse,  in  setting  up  the  room,  may  make 
provision  for  their  arrangement. 


PREPARATION  OF  THE  ROOM  AND  IIS  EQUIPMENT  IN  A  PRIVATE  HOUSE        33 

INSTRUMENT  TABLE 

The  surgeon  may  or  may  not  send  with  the  kit  the  instruments  he  will 
require.  In  either  event,  there  must  be  provided  an  instrument  table, 
which  is  protected  by  a  sterile  sheet  (Fig.  8).  The  instruments  must,  of 
course,  be  sterilized,  and  this  is  accomplished  by  boiling  for  at  least  twenty 
or,  better,  thirty  minutes.     Passing  time  has  witnessed  the  proposal  of  this 


Fig.  8. — Table  of  Sterile  Instruments. 
The  instruments  are  grouped  as  follows:  (i)  Scalpels;  (2)  scissors;  (3)  pedicle  clamps;  (4)  re- 
tractors; (5)  Mayo-Ochsner's  artery   forceps,    straight;  (6)  Ochsner's  artery  forceps,  curved;  (7) 
Thornton's  artery  forceps,  curved;  (8)  special  instruments;  (9)  tissue  forceps;  (10)  sponge  sticks; 
(11)   Kelly-Hals tead  artery  forceps;  (12)  Pean's  artery  forceps. 


or  that  method  of  instrument  sterilization,  only  to  have  it  demonstrated 
in  the  end  as  unreliable  and  not  as  effective  as  the  simple  process  of  boiling. 
Almost  any  sort  of  container  may  be  used ;  a  dish  pan  or  bread  tins  will  do. 
The  instruments  are  to  be  submerged  entirely  in  water.  Here  it  is  well  to 
note  that  well  or  tap  water  is  preferable  to  rain  water.  Rain  water,  as  a 
rule,  contains  much  organic  matter  and  objectionable  dirt.  The  well 
water  or  tap  water  used  should  be  made  slightly  alkaline  by  the  use  of 


34 


SURGICAL   NURSING 


soda,  common  washing  soda  or  sodium  hydroxid.     When  using  the  latter, 
an  alkahnity  of  i  in  loo  is  recommended. 

There  has  been  considerable  discussion  as  to  whether  or  not  boiling 
destroys  the  cutting  edges  of  knives  or  scissors.  It  is  still  a  mooted  ques- 
tion, and  the  nurse  will  find  that  some  surgeons  do  not  object  to  having 
their  scalpels  and  scissors  boiled,  while  others  will  strenuously  object.  In 
the  latter  event,  the  cutting-edged  instruments  must  not  be  placed  with  the 
other  instruments   for   sterilization  by  boiling.     Such  instruments  are 


.ff.' 


Fig.  9. — Arrangement  op  Scrubbing-up  Articles  on  Improvised  Bench. 
The  articles  shown  are  as  follows :  Three  basins  for  scrubbing,  two  pitchers  of  sterile  water,  three 
sterile  brushes,  cup  for  iodin,  cup  for  hydrogen  peroxid,   bottle   of  hydrogen  peroxid,  bottle  of 
green  soap,  bottle  of  iodin,  basin  of  antiseptic  solution,  basin  of  alcohol,  orange  sticks. 

usually  rendered  sterile  by  immersion  in  antiseptic  solutions.  One  of  the 
most  common  methods  is  to  immerse  them  for  twenty  minutes  in  95  per 
cent,  carbolic  acid  solution  and  then  place  them  in  70  per  cent,  alcohol 
until  called  into  use.  Of  the  two  methods,  I  believe  that  boiling  and  im- 
mersion in  alcohol  is  the  method  that  insures  greater  asepsis,  and  that  this 
method  does  not  in  the  least  affect  the  cutting  edge.  You  must  be  guided 
in  this,  however,  entirely  by  the  surgeon's  wishes,  and,  if  unfamiliar  with 
them,  it  is  your  duty  to  ask  him  to  express  his  preference.  Having  done 
so,  you  should  follow  it  regardless  of  your  personal  opinions. 

After  having  been  subjected  to  boiling  for  the  allotted  time,  the  instru- 
ments are  removed  under  aseptic  precautions  and  placed  upon  a  sterile 
towel  on  one  end  of  the  instrument  table.     They  are  then  to  be  dried  with 


PREPARAIION  OF  THE  ROOM  AND  ITS  EQUIPMENT  IN  A  PRIVATE  HOUSE        35 

a  Sterile  towel  and  laid  out  in  order  upon  the  table.  A  pair  of  scissors  for 
cutting  sutures,  and  the  needles  as  well  as  the  needle  holders  are  trans- 
ferred to  the  sterile  goods  table.  One  who  has  had  experience  in  various 
operations  will  know  about  how  many  of  the  different  sutures  will  be 
required  in  the  operation,  and  she  will,  of  her  own  accord,  before  the  sur- 
geon commences  his  work,  thread  the  various  needles  with  sutures,  thus 
having  them  ready  for  the  surgeon  before  he  asks  for  them. 

It  was  a  universal  custom  at  one  time  for  a  nurse  to  have  a  basin  of 
sterile  water  on  the  instrument  table,  which  was  used  to  remove  blood- 
stains from  the  instruments.  This  is  no  longer  considered  good  practice. 
Instruments  that  have  been  used  once  and  laid  down  should  be  gathered 
up  by  the  nurse,  put  aside,  and  not  be  permitted  to  be  used  again.  The 
basin  formerly  used  to  wipe  off  these  instruments  is  now  used  to  hold  the 
soiled  or  used  instruments.  This  is  the  ideal  practice  and  a  distinct  step  in 
the  advance  of  operative  technique.  Of  course,  if  the  surgeon  has  not 
provided  himself  with  a  sufficient  number  of  instruments  to  permit  such  a 
practice,  the  nurse  will  then  have  to  attend  to  keeping  the  instruments 
free  from  bloodstains. 

The  operation  completed,  all  the  instruments,  whether  they  have  been 
used  or  not,  should  be  boiled  again  in  alkaline  water  and  carefully  dried. 
I  wish  to  reiterate  the  caution- — carefully  dried-,  because  it  may  be  several 
hours  before  the  surgeon  is  able  to  return  the  instruments  to  his  private 
nurse  or  hospital,  and  in  that  time  they  may  rust  to  such  an  extent  as  to 
damage  the  more  delicate  ones  and  render  them  unfit  for  future  use. 
Therefore,  exert  sufficient  effort  to  prevent  such  a  mishap,  and  be  sure 
that  all  the  instruments  are  thoroughly  dried  before  being  packed  in  the 
surgeon's  bag.  Scalpels,  scissors,  and  all  cutting  instruments  should  have 
their  edges  protected  by  means  of  cotton  if  they  are  without  special  carry- 
ing cases. 

The  work  of  boiling  and  drying  the  instruments  should  take  place 
immediately  after  the  completion  of  the  operation  in  order  that  the  surgeon 
may  take  them  with  him.  He  cannot  allow  you  to  postpone  this  duty 
until  a  more  convenient  time,  for  he  does  not  know  at  what  moment  he 
may  be  called  upon  to  use  them  in  another  case.     If  needed  soon,  it  would 


36  SURGICAL   NURSING 

be  time-consuming  and  annoying  to  have  to  send  or  make  a  special  call  to 
obtain  them.  He  will  appreciate  your  promptness  in  this  respect  and  also 
the  care  and  neatness  with  which  you  pack  them  in  his  instrument  case. 

DISMANTLING  THE  ROOM 

The  operation  completed,  the  patient  returned  to  bed,  the  surgeon's 
instruments  boiled,  dried,  and  packed  in  his  bag,  the  task  of  dismantling 
the  improvised  operating  room  should  be  undertaken  immediately,  and  all 
traces  of  the  use  to  which  the  room  has  been  put  should  be  speedily 
removed. 

Here,  again,  a  methodical  course  will  enable  the  nurse  to  complete  this 
duty  with  the  greatest  speed.  All  the  dressings  that  were  not  used  should 
be  given  to  the  nurse  who  remains  on  the  case  for  resterilization  and  use  in 
subsequent  dressings.  Place  a  large  newspaper  in  one  corner  of  the  room 
and  upon  this  collect  all  the  soiled  and  useless  dressings  and  material  to 
be  destroyed.  When  all  such  material  has  been  collected,  it  may  be 
wrapped  up  and  carried  to  a  fire  and  burned. 

The  surgical  gowns,  if  badly  soiled  with  blood,  should  be  rinsed  out  in 
cold  water  and  dried  immediately  by  means  of  artificial  heat,  and  then 
folded  and  packed  in  the  kit.  All  the  returnable  goods  are  to  be  collected 
and  returned  to  their  containers,  and  the  kit  returned  to  the  hospital  as 
promptly  as  possible.  It  is  unpardonable  to  retain  possession  of  this  kit 
for  a  longer  time  than  is  necessary  to  remove  the  bloodstains  from  the 
gowns  and  to  pack  it. 

The  foregoing  directions  leave  undisposed  of  only  the  furniture  and 
sheets  that  were  used  in  setting  up  the  room.  These  should  be  taken  down, 
folded,  and  given  to  a  member  of  the  family  or  servant  to  be  sent  to  the 
laundry.  In  like  manner,  the  utensils  used  are  cleansed  and  returned  to 
their  sources.  The  assistance  of  members  of  the  family  is  then  secured 
and  the  room  resettled  with  its  customary  furniture. 

A  word  of  caution  that  should  be  ever  in  the  nurse's  thoughts  while 
preparing  an  operating  room  in  a  private  home — perform  your  work  in 
such  manner  and  with  such  care  as  to  cause  as  little  damage  to  the  room  as 
possible.     While  the  owner  of  the  home  will  usually  consent  to  property 


PREPARAIION  OF  THE  ROOM  AND  ITS  EQUIPMENT  IN  A  PRIVATE  HOUSE        37 

damage,  if  in  so  doing  the  safety  of  the  patient  will  be  enhanced,  one  should 
always  remember  that  ruthless  and  needless  marring  of  walls  or  furniture 
renders  one  culpable. 

In  conclusion,  the  surgical  nurse  must  remember  that  the  safety  of  the 
patient  depends  upon  her,  as  one  of  the  group  of  actors  in  the  operative 
drama,  and  that  the  faithfulness  with  which  she  discharges  her  duty  will 
have  a  distinct  influence  upon  the  final  result.  The  safety  of  the  patient  is 
dependent  upon  the  thoroughness  of  your  technique  and  your  observance 
of  the  rules  of  asepsis.  With  this  clear  understanding  before  you  at  all 
times,  there  can  be  no  hesitation  as  to  the  way  you  acquit  yourself.  You 
are  intrusted  with  a  sacred  duty;  you  cannot  afford  to  violate  the  trust 
imposed  on  you  if  you  are  desirous  of  gaining  a  reputation  as  a  capable  and 
efficient  surgical  nurse. 


CHAPTER  III 
METHODS  OF  HAND  STERILIZATION 

Present-day  surgical  procedures  have  been  made  possible  and  their 
detailed  requirements  perfected  by  reason  of  the  development  of  an  aseptic 
technique.  It  is  not  so  many  years  ago  that  operative  work,  even  in 
minor  surgery,  was  an  extremely  perilous  undertaking,  being  attended 
with  a  high  rate  of  mortality  due  solely  to  wound  infection.  The  dread 
of  the  operative  risk  caused  many  a  patient  to  endure  his  condition  rather 
than  venture  a  chance;  for  it  was  chance  which  determined  whether  or 
not  the  work  of  the  surgeon  was  undone  by  subsequent  infection  through  a 
lack  of  knowledge  and  application  of  the  principles  of  asepsis. 

Today  all  this  is  changed.  The  surgeon,  physician,  and  nurse  are  in 
possession  of  knowledge  that  enables  them  to  state  that  surgery  may  be 
resorted  to  with  but  little  dread  of  septic  catastrophe.  They  can  make 
this  statement  by  reason  of  their  knowledge  of  bacteria  and  the  known 
avenues  by  which  infection  is  introduced.  With  a  knowledge  of  the 
mode  of  transmission  and  implantation  of  bacteria  and  of  the  means  by 
which  they  may  be  destroyed,  it  is  possible  to  lessen  the  danger  of  their 
entrance  and  destructive  action  in  the  operative  field  or  wound. 

To  prevent  infection  and  to  observe  an  aseptic  surgical  technique,  it  is 
essential  that  one  possess  a  fundamental  knowledge  of  bacteriology. 
It  is  not  within  the  province  of  this  chapter  to  impart  such  knowledge  in 
detail,  but  a  few  of  the  elementary  principles  of  bacteriology  are  stated 
that  later  observations  may  be  more  clearly  understood. 

Bacteria  and  their  spores  have  been  demonstrated  as  the  exciting 
factors  of  infection  and  its  subsequent  train  of  symptoms.  It  is  conceded 
that  they  are  introduced  from  without  and,  in  certain  instances,  may 
arise  from  within.  It  is  their  presence  together  with  their  products  in 
the  body  that  causes  the  several  conditions  known  as  septic  infections. 
In  surgery,  the  term  sepsis  or  septic  is  a  general  one,  employed  to  convey 

38 


METHODS    OF   HAND    STERILIZATION  39 

the  information  that  microorganisms  have  appeared.  The  terms  are 
void  of  specific  meaning.  To  be  exphcit  one  must  determine  the  par- 
ticular form  of  organism.  This  is  possible,  in  most  instances,  by  means  of 
a  microscopical  examination  of  the  wound  discharges  or  of  cultures  ob- 
tained from  the  blood  stream  or  body  secretions. 

It  has  been  demonstrated  that  the  results  of  sepsis  are  not  due  primarily 
to  the  bacteria  but  to  the  absorption  of  those  products  formed  by  the 
chemical  action  that  takes  place  after  the  microorganisms  multiply  and 
grow  in  the  wound  and  surrounding  tissues. 

Our  bacteriologists  have  isolated  and  described  the  following  common 
forms  of  bacteria  most  frequently  found  in  wounds  considered  as  infected 
or  septic: 

Staphylococcus  pyogenes  albus  and  aureus.  Pneumococcus. 

Bacillus  coli  communis.  Bacillus  typhosus. 

Streptococcus  pyogenes.  Bacillus  diphtherias. 

Bacillus  pyocyaneus.  Aerogenes  capsulatus. 

Bacillus  tuberculosis.  Bacillus  tetani. 
Gonococcus. 

The  reader  is  referred  to  a  textbook  on  bacteriology  for  the  salient 
characteristics  of  these  organisms. 

It  was  first  demonstrated  by  Wright,  and  since  confirmed  by  numerous 
investigators  and  clinicians,  that  there  exists  in  the  human  body  a  force 
capable  of  producing  certain  substances  called  antibodies,  or  opsonins , 
which  possess  the  power  of  inhibiting  or  rendering  inert  those  microor- 
ganisms that  bring  about  septic  conditions.  This  is  the  barrier  that 
Nature  throws  out  for  self-preservation  and  to  ward  off  bacterial  invasion. 
In  the  state  of  health  such  a  defense,  in  most  instances,  is  sufiicient.  By 
reason  of  disease,  however,  or  any  undermining  condition  that  deflects 
the  physiological  functions  from  the  normal  and  so  creates  a  lowered 
physical  state.  Nature  is  incapable  of  throwing  out  a  sufficiently  strong 
barrier  to  overcome  microorganic  invasions.  The  barrier  is  broken 
through,  the  infection  gains  a  foothold,  characteristic  symptoms  and 
conditions  are  produced,  and  then  that  state  known  as  sepsis,  or  infection, 
is  established,  carrying  with  it  its  dismal  troop  of  potential  eventualities. 

When  such  a  calamity — for  the  onset  of  an  infective  process  is  nothing 


40  SURGICAL   NURSING 

short  of  a  calamity — occurs  and  gains  a  firm  foothold,  our  duty  lies  in  an 
endeavor  to  overcome  and  render  innocuous  the  invading  organisms. 
Many  have  been  the  plans  of  attack  that  have  been  devised;  many  of 
them  have  fallen  short  of  being  what  may  be  termed  reliably  effective  or 
dependable.  For  this  reason  the  laboratory  worker  has  been  appealed 
to  and  urged  to  supply  us  with  an  effective  combating  agent.  As  a  result, 
we  have  had  presented  to  us  the  principles  of  serum  therapy  with  its  serums, 
antitoxins,  and  autogenous  vaccines  which,  though  not  as  yet  completely 
understood,  promise  much  toward  supplying  us  with  extremely  potent 
combating  agents. 

This  brief  explanation  of  bacterial  infection  is  employed  as  an  introduc- 
tion to  this  chapter  for  the  purpose  of  impressing  upon  the  reader  the 
importance  of  a  knowledge  of  bacteriology  when  preparing  oneself  for 
operative  work.  What  has  been  aptly  termed  an  aseptic  conscience  is 
imperative  for  the  development  of  a  modern  surgical  technique.  Unless 
a  nurse  knows  the  cause,  development,  prevention,  remedial  agents,  and 
methods  for  combating  infection,  she  should  not  be  intrusted  with  the 
duties  a  surgical  nurse  is  called  to  perform.  The  principles  of  asepsis, 
therefore,  merit  your  persistent  study  and  observation. 

How  may  these  infective  organisms  gain  entrance  into  an  operative 
wound?  This  is  difficult  to  determine  exactly,  for  there  are  times  when, 
after  the  greatest  precautions  have  been  taken,  the  succeeding  days  reveal 
a  septic  infection.  This  is  the  reason  that  present-day  methods  call  forth 
the  need  of  exercising  to  the  fullest  extent  the  principles  that  have  been 
established  to  prevent  wound  infection  during  any  surgical  operation. 
The  most  common  routes  of  invasion  are  from  the  use  of  improperly 
sterilized  instruments,  sutures,  drainage  material,  sponges,  dressings,  and 
the  hands  of  the  surgeon,  his  assistants,  or  nurses;  in  fact,  anything  that 
comes  in  contact  with  the  wound  or  is  touched  while  working  in  an 
artificial  opening  through  the  cutaneous  surface  may  bear  the  germs  of 
infection.  Knowing  this,  no  operative  undertaking  today  may  be  ap- 
praised as  safe  until  every  act  connected  therewith  has  been  safeguarded 
by  those  methods  that  have  been  proved  efficient  in  preventing  contamina- 
tion of  a  wound.     It  is  this  knowledge  that  has  developed  aseptic  surgery 


METHODS    OF    HAND    STI::R1LIZATI0N 


41 


and  made  imperative  the  institution  of  sterilization  as  a  prophylactic 
measure. 

This  prophylactic  precaution  is  accomplished  by  means  of  certain 
fairly  definite  steps.  One  of  these  steps  was  described  in  our  previous 
chapter  devoted  to  the  preparation  of  the 
operating  room.  The  second  step  is  the 
preparation  of  the  hands  of  those  who  come 
in  contact  with  the  wound.  The  third  step 
is  the  preparation  of  the  patient  and  the  field 
of  operation,  which  will  be  taken  up  in  our 
next  chapter.  This  brings  us  then  directly 
to  our  present  subject: 

PREPARATION  OF  THE   HANDS— SCRUBBING   UP 

When  it  was  first  determined  that  the 
hands  of  the  principals  in  an  operation  were 
carriers  of  infectious  bacteria,  many  and 
various  methods  or  procedures  of  hand 
sterilization  were  advanced.  No  sooner 
was  a  method  proposed  than  its  deficiencies 
were  pointed  out  and  another  method  was 
advocated.  So  the  pendulum  swung  from 
one  method  and  extreme  to  another.  From 
all  the  discussion,  experimenting,  debating, 
and  testing,  however,  there  eventually 
emerged  several  methods  that  have  with- 
stood the  tests  imposed  and  are  conceded 
as  dependable  and  reliable.  Some  of  these  are  most  elaborate  and 
complex,   others  are  comparatively  simple,  but  none  the  less  efficacious. 

In  our  leading  clinics  and  hospitals  today  two  methods  are  chiefly 
employed  in  the  preparation  or  sterilization  of  the  hands.  It  is  essential 
that  a  surgical  nurse  be  familiar  with  both  methods.  In  referring  to  the 
hands,  it  must  be  understood  that,  in  a  surgical  sense,  we  mean  the  hands 
and  arms  up  to  the  elbows. 


Fig.  10. — Scrubbed  Nurse 
IN  Sterile  Gown  and  Gloves 
Ready  to  Work. 


42  SURGICAL   NURSING 

All  of  the  methods  of  hand  sterilization  call  for  scrubbing  with  soap 
and  warm  water  for  a  period  of  at  least  ten  minutes.  In  hospitals  where 
scrub  rooms  are  provided  in  the  operating  suite,  the  scrubbing  is  done  under 
taps  qf  running  cold  and  hot  sterile  water.  In  a  private  home,  without 
these  conveniences,  we  are  forced  to  use  hand  basins  containing  the 
scrub  water.  In  this  event  we  must  secure  and  provide  a  sufficient  amount 
of  water  to  allow  frequent  changes. 

Many  brands  of  soap  of  various  formulae  have  been  marketed  for  this 
surgical  procedure.     Some  of  them  are  of  value,  others  are  valuable  in 


Fig.  II. — Nurse's  Hands  Showixg  Two  Pairs  of  Rubber  Gloves. 

name  only.  The  most  satisfactory  are  our  common  tincture  saponis 
viridis,  or  green  soap,  a  standard  soft  soap,  and  ivory  soap.  The  simple 
"soaping"  of  the  hands  is  insufficient;  hand  scrub  brushes  are  employed. 
While  there  are  some  who  object  to  that  use  of  scrub  brushes  for  the  reason 
that  they  are  said  to  produce  a  trauma  of  the  hands,  the  objection  thus 
raised  is  trivial.  These  objectors  employ  a  washcloth,  but  the  use  of 
scrub  brushes  is  fairly  universal. 

Before  describing  the  methods  of  scrubbing  up,  it  may  be  well  to  insert 
a  brief  paragraph  on  the  wearing  apparel  of  those  engaged  in  an  operation. 
The  days  are  past  when  the  good  old  doctor  or  professor  entered  the 
operating  room  wearing  his  street  clothes,  white  boiled  shirt,  and  starched 
collar,  and  simply  laid  his  top  coat  and  cuffs  aside,  rolled  up  his  sleeves, 


METHODS    OF    HAND    STERILIZATION 


43 


washed  his  hands  in  a  Uttle  water,  and  proceeded  to  operate.  Surgery 
today  demands  that  we  give  the  same  attention  to  the  cleaning  of  our 
bodies  and  to  the  wearing  of  suitable  operating-room  clothes  as  we  do  to  our 
hands  and  instruments.  It  is  hardly  necessary  to  mention  that  a  general 
bath  is  essential  on  the  day  of  opera- 
tion. Before  entering  the  scrub  room 
one  should  don  an  operating  suit  and 
shoes  that  are  freshly  laundered  and 
which  may  well  be  sterilized  the  same 
as  are  the  dressings.  The  surgeon  and 
his  assistants  usually  wear  a  shirt,  white 
canvas  trousers,  and  white  canvas  shoes 
during  all  major  operations,  and  also  in 
minor  operations  when  a  general 
anesthetic  is  used  or  sterile  work  is 
done.  The  nurse  should  wear  a  clean 
uniform  and  canvas  shoes.  She  should 
be  particular  to  be  comfortably  dressed; 
tight  wearing  apparel  that  restricts  or 
retards  free  physical  movements  must 
be  avoided. 

Before  beginning  the  process  of 
scrubbing,  one  should  carefully  mani- 
cure the  finger  nails.  The  nails  should 
be  kept  trimmed  round  and  close — not 
pointed.  Just  before  scrubbing,  what- 
ever dirt  may  have  become  lodged  under  the  finger  nails  should  be  re- 
moved by  means  of  an  orange  stick  and  peroxid  of  hydrogen.  Next, 
the  headpiece  should  be  put  on,  one  that  entirely  covers  the  hair,  and 
following  this  the  nose  and  mouth  mask.  In  several  places  we  have 
noticed  that  this  covering  for  the  hair,  nose,  and  mouth  is  neglected 
until  after  the  scrubbing  process  is  completed.  This  is  an  error  in 
technique  which  should  not  be  overlooked.  Thus  clothed  and  prepared, 
one  is  ready  to  commence  to  scrub. 


Fig.  12. — Surgeon  Properly  Gowxed 
AND  Gloved. 


44 


SURGICAL   NURSING 


The  scrubbing  of  the  hands,  necessarily,  must  be  a  perfunctory  and 
ineffective  proceeding  unless  we  remain  conscious  of  the  purpose  for 
which  we  are  employing  this  precaution  and  endeavor  to  attain  the  bene- 


YiG.  13. — Preparation  of  the  Hands  When  Running  Water  is  Not  Available.     Nurse 

Scrubbing. 


Fig.  14. — Going  through  Solutions.     Rinsing  off  Soap. 


ficial  results  of  the  method.     It  should  be  a  procedure,  therefore,  charac- 
terized by  methodical  completeness. 

The  materials  and  the 'preliminary  scrubbing  may  be  outlined  as 
follows: 


METHODS    OF    HAND    STERILIZATION 


45 


1.  Running  hot  tap  water  or  basins  containing  sterile  water. 

2.  An  ample  supply  of  suitable  soap. 

3.  Scrub  brushes. 

4.  Wetting  the  hands  and  arms  thoroughly. 


Fig.  15. — Applying  70  Per  Cent.  Alcohol. 


Fig.  lb. — Scrub  Room. 
Note  one  surgeon  scrubbing  up,  dressed  in  duck  shirt,  trousers  and  shoes  with  face  mask 
and  headgear  on.     Note  handles  for  controlling  water  by  knee  pressure.     Note   sand  glass, 
10  minutes,  to  accurately  time   scrubbing.     The   surgeon's   assistant   has  finished  scrubbing 
and  is  cleaning  his  hands  in  the  antiseptic  solutions.     A  section  of  supply  cupboards. 

5.  Rubbing  in  an  ample  amount  of  soap,  which  is  worked  into  a  lather,  covering  the  entire  surface 
of  the  hands. 

6.  Rinsing  off  this  first  lather. 

7.  Resoaping. 


46  SURGICAL   NURSING 

8.  Scrubbing  with  a  brush  or  cloth  in  a  sj^stematic  manner,  commencing  with  the  thumb,  and  in 
succession  scrubbing  the  inner  and  outer  surfaces  of  the  thumbs  and  fingers  of  both  hands,  then  the 
palms  and  dorsa  of  the  hands  and,  lastly,  the  forearms.  Ten  minutes  is  to  be  thus  employed,  all 
the  while  using  a  sufficient  amount  of  soap  and  water.  The  more  thoroughly  we  scrub  the  more 
bacteria  are  removed. 

9.  Thoroughly  rinse  off  the  soap — not  by  a  simple  dab  or  splash  in  the  water,  but  thoroughly 
remove  every  trace  of  soap.  This  is  important.  If  it  is  not  done,  the  antiseptic  solutions  subse- 
quently employed  will  be  inert,  for  the  almost  indiscernible  film  of  soap  covering  the  skin  will  prevent 
antiseptic  action.  This  precaution  is  frequently  overlooked;  therefore,  be  sure  to  secure  a  complete 
rinsing  with  as  hot  water  as  can  be  borne  to  remove  all  the  soap  and  oils  or  fats  of  the  soap  which  form 
a  coating  over  the  skin. 

• 

The  next  step  in  hand  sterilization  is  accompHshed  by  the  use  of  certain 
chemical   antiseptic   solutions   of  known   germicidal  power.     They   are 


Fig.  17. — Applying  Iodin  to  Nails. 

demanded  for  the  ideal  procedure  in  our  endeavor  to  secure  as  perfect 
aseptic  preparation  as  possible.  Their  nature  and  chemical  formulae 
are  numerous  and  varied  in  character.  Some  of  them  are  potent,  some 
are  not.  Some  are  reliable,  some  only  partially  so;  a  few  are  wholly  with- 
out antiseptic  properties,  either  because  of  their  nature  or  the  manner  in 
which  they  are  used.  The  following  are  the  more  frequently  used  anti- 
septics in  varying  solutions: 

Carbolic  acid.  Tincture  of  iodin. 

Lysol.  Alcohol. 

Bichlorid  of  mercury,  or  mercuric  chlorid.  Potassium  permanganate. 

About  ten  years  ago  the  late  Nicholas  Senn  caused  his  assistants  to 
undertake  a  series  of  experiments  and  investigations  with  the  object  of 
determining  the  length  of  time  required  for  different  chemical  antiseptic 
agents  of  various  strength  and  solutions  to  destroy  bacteria  and  render 


METHODS    or    HAND    STERILIZATION  47 

them  and  their  spores  inert.     The  result  of  these  experiments^  has  been 
condensed  as  follows : 

The  germicidal  power  of  iodin  is  far  superior  to  that  of  bichlorid  of  mercury,  the  acknowledged 
leader  of  all  antiseptics.  This  was  shown  by  experiments  made  with  a  i  in  loo  solution  of  bichlorid 
of  mercury  on  the  streptococcus  pyogenes.  It  was  found  that  an  exposure  of  fifteen  minutes,  al- 
though showing  considerable  inhibitory  power,  permitted  a  good  growth  of  streptococci  to  appear. 
An  exposure  of  thirty  minutes  gave  no  growth.  The  superiority  of  iodin  is  readily  evidenced  by  the 
experiments  that  showed  the  destruction  of  the  streptococci  after  two  minutes'  exposure  in  a  0.2 
per  cent,  solution. 

A  I  in  40  solution  of  carbolic  acid  requires  ten  minutes  to  kill  the  streptococcus. 

It  takes  thirty  minutes  for  a  i  in  1000  solution  of  bichlorid  to  kill  the  bacillus  of  anthrax. 

Ten  hours  are  required  for  a  i  in  1000  solution  of  bichlorid  to  kill  the  tetanus  bacillus. 

Alcohol,  70  per  cent.,  requires  five  minutes  to  be  effective. 

Iodin  in  0.5  per  cent,  solution  is  amply  strong  enough  for  all  uses. 

Thus  was  it  demonstrated  how  utterly  useless  it  is  for  one  to  immerse 
his  hands  or  arms  in  a  solution  of  bichlorid  for  but  a  minute  or  two  and 
feel  content  and  safe  that  infective  bacteria  are  destroyed.  To  use  a  dis- 
infectant effectively  demands  that  the  hands  and  arms  be  immersed  in  it 
for  the  entire  time  required  to  destroy  the  several  bacteria — from  five  to 
forty-five  minutes — and  then  we  are  not  sure  that  the  tetanus  bacillus  or 
even  the  streptococci  and  staphylococci,  if  present,  are  destroyed.  On  the 
other  hand,  a  solution  of  iodin  kills  and  destroys  the  spores  of  every 
infecting  organism  in  a  space  of  two  or  three  minutes  if  used  in  the  recom- 
mended strength,  many  of  them  being  destroyed  at  the  moment  of  contact. 
Iodin  has  an  additional  value,  namely,  its  penetrating  property. 

I  cannot  but  wonder  how  these  conclusions  will  impress  those  who  have 
been  accustomed  simply  to  dip  their  hands  in  a  solution  of  bichlorid  of 
mercury  with  the  thought  that  by  so  doing  they  were  rendering  them  free 
from  bacterial  contamination.  Such  a  method  is  little  better  than  employ- 
ing so  much  water.  Thus,  too,  is  it  demonstrated  that  the  mere  trickling 
of  a  solution  of  bichlorid  over  the  operative  field  is  of  little  value.  In  this 
instance  the  scrubbing  with  soap  and  water  is  the  most  efi'ective  antiseptic 
agent.  The  more  thorough  the  scrubbing,  the  fewer  bacteria  will  there 
be.  There  are  some  who  depend  upon  scrubbing  alone  and  do  not  use  any 
bacterial  destroying  agents.  The  final  process  of  hand  sterilization  should 
consist  of  the  following: 

^  Surgery,  Gynecology,  and  Obstetrics,  Vol.  I,  No.  i,  Jul}^,  1905. 


48  SURGICAL   NURSING 

1.  The  introduction  of  a  50  per  cent,  tincture  iodin  solution  in  alcohol  under  the  finger  nails  and 
around  the  matrices  by  means  of  an  orange  stick. 

2.  The  rubbing  into  the  skin  of  the  fingers  and  palms  of  the  hands  this  same  strength  iodin  for 
a  period  of  at  least  two  minutes.  Here  it  must  be  noted  that  iodin  rapidly  loses  its  full  strength. 
The  more  recent  its  preparation  the  more  potent.  Iodin,  thus  employed,  should  not  be  more  than 
one  week  old.     This  method  does  not  cause  exfoliation  or  blistering  of  the  skin. 

3.  The  bathing  of  the  hands  and  arms  in  70  per  cent.,  alcohol  for  a  period  of  at  least  three  or  four 
minutes.  This  is  best  accomplished  by  having  a  sterile  sponge  to  apply  the  alcohol  in  a  manner 
similar  to  the  use  of  a  washcloth.  By  this  means  all  traces  of  the  staining  properties  of  the  iodin 
are  removed.  The  alcohol  is  not  dried  o£f  by  means  of  towels;  it  is  allowed  to  evaporate,  and  while  it 
is  evaporating,  one  ma}^  proceed  to  put  on  the  sterile  gown. 

This  is  a  reliable  method  of  hand  sterilization  which  repeated  tests 
have  proved  entirely  satisfactory  and  efficacious. 

The  following  methods  will  be  found  in  use  in  several  clinics : 

The  Welch-Kelly  Method. — After  a  thorough  scrubbing  of  the  hands 
and  forearms,  they  are  immersed  in  a  saturated  solution  of  permanganate 
of  potassium  for  two  or  three  minutes.  This  causes  the  cutaneous  surface 
to  become  very  dark  brown.  The  hands  and  arms  are  then  immersed  in  a 
warm  solution  of  oxalic  acid,  of  saturated  strength,  until  all  the  stain  of  the 
permanganate  is  removed.  They  are  then  thoroughly  rinsed  in  sterile 
water  and  immersed  for  two  minutes  in  a  i  in  5000  solution  of  bichlorid, 
rinsed  in  sterile  water,  and  dried  on  a  sterile  towel.  For  some,  this  method 
is  very  irritating  to  the  skin  and  cannot  be  endured  for  any  length  of  time. 

The  Weir-Stimson  Method. — After  the  hands  are  scrubbed,  a  table- 
spoon of  chlorinated  lime,  a  piece  of  crystalline  carbonate  of  soda,  and  a 
little  water  are  mixed  in  the  palm  of  one  hand,  and  the  resulting  creamy 
mixture  is  thoroughly  rubbed  into  the  skin  until  the  rough  granules  of  the 
soda  are  no  longer  felt.  This  requires  from  three  to  five  minutes.  The 
hands  are  then  rinsed  in  sterile  water.  The  disagreeable  odor  of  the  lime  is 
removed  by  the  use  of  sterile  ammonia  water  in  the  strength  of  H  to  i  per 
cent.  The  value  of  the  procedure  rests  in  the  free  chlorin  that  is  thus 
liberated. 

The  Sublimate -Alcohol  Method. — After  scrubbing,  the  soap  is  removed 
by  dipping  the  hands  in  95  per  cent,  alcohol.  The  hands  are  then  immersed 
in  70  per  cent,  alcohol  containing  i  part  in  1000  of  corrosive  sublimate 
for  a  period  of  three  minutes,  using  a  piece  of  sterile  gauze  to  work  in  the 
solution.     Lastly,  the  hands  are  rinsed  in  sterile  water. 


METHODS    OF   HAND    STERILIZATION 


49 


Fig.  1 8. — Putting  on 
Sterile  Gown,  Hands  in 
THE  Sleeves  of  the  Gown. 


Fig.  iq.^Sliding  into  the  Gown      ^^' 


Fig.  20. — Unsterile  Nxirse 
Tying  the  Gown.  Sterile 
NiiRSE  Tying  the  Tapes  of 
THE  Sleeves. 


50 


SURGICAL   NURSING 


Oil  of  Cloves  Method. — After  scrubbing,  the  hands  are  immersed  in  a 
I  in  1000  solution  of  bichlorid.  This  is  followed  by  rubbing  in  one  or 
two  drams  of  pure  oil  of  cloves,  which  is  subsequently  removed  by  a 
vigorous  washing  in  70  per  cent,  alcohol. 

Lysol  Method. — Immerse  the  hands  in  i  in  1000  bichlorid,  followed 
by  a  I  in  10  solution  of  lysol  and  then  70  per  cent,  alcohol. 


'3J 


%       ■* '  ■' 


"ittm^ 


t 


*>»-i 


mm^ 


Fig.  21. — Preparing  for  Operation. 
Note   method  in  which   nurse   holds    doctor's   gloves    to  assist  putting  them  on.     Dry 
gloves.     Unclean  nurse  fastening  gown  in  back.     Assistant  ascertaining  whether  all  necessary 
instruments  are  on  the  instrument  tray. 

Many  are  of  the  opinion  that  the  value  of  these  methods  lies  solely  in 
the  protection  that  is  afforded  by  the  alcohol.  This  is  a  debatable  ques- 
tion and,  in  spite  of  the  evidence  that  is  submitted,  some  will  be  found  who 
will  not  desert  the  method  which  they  have  been  accustomed  to  employ. 
Our  aim  should  be  to  use  as  simple  a  method  as  is  consistent  with  potency 
in  attaining  the  desired  end — hands  that  are  rendered  as  sterile  as  it  is 
possible  to  make  them.  You,  as  nurse,  will  be  compelled  at  times  to 
follow  the  fancy  of  the  surgeon  whom  you  are  assisting  and,  since  he  is 


METHODS    OF   HAND    STERILIZATION 
PUTTING  UP  DRY  STERILE  GLOVES 


5^ 


Fig.  22. — Preparations  Completed. 

On  the  table  are  boiled  gloves  (tied  in  pairs)  in  sterile  basin,  dusting  powder,  stack   of  towels> 

powder  basin,  and  stack  of  glove  envelopes,  all  sterile. 


Fig.  23. — Gloves,  Towels,  Basin,  and  Envelopes  are  Kept  Covered  with  Sterile  Towels 

During  the  Process. 


52 


SURGICAL   NURSING 


Fig.  24. — Reaching  under  Protecting  Towel  for  Pair  of  Gloves. 


Fig.  25. — Drying  the  Boiled  Gloves  with  a  Sterile  Towel. 


METHODS    OF   HAND    STERILIZATION 


53 


0-' 


^C^ 
< 


Fig.  26. — DippixG  Gloves  ix  Pot\'der  Basix. 


i^^lS^^ 


Fig.  27. — TiTRXixG  Glove  that  has  beex  Powdered  ox  Oxe  Side  so  That  the  Other  Side  may 

EE  Powdered  Also. 


54 


vSURGICAL   NURSING 


Fig.  28. — Putting  the  Gloves  in  a  Sterile  Cloth  Envelope. 


Fig.  29. — Closing  Cloth  Envelope. 


METHODS    OF   HAND    STERILIZATION 


55 


ii 


Fig.  30. — First  Step  of  Wrapping  Envelope  in  Protective  Covering. 


Fig.  ^i. — Pinning  First  Fold  of  Protective  Wrapper. 


56  SURGICAL   NURSING 

responsible  for  the  operative  results  and  the  acts  of  all  those  engaged  in  it, 
he  may  rightly  dictate  the  method  you  are  to  follow.  Others  will  rely 
upon  your  training  and  will  tell  you  to  employ  the  most  effective  means. 

Until  within  recent  years  it  was  customary  to  engage  in  surgical  work 
with  the  hands  thus  prepared.  Now  an  additional  safeguard  for  surgeon 
and  patient  is  utilized,  namely,  the  wearing  of  sterile  rubber  gloves. 
Professor  Halstead  of  Baltimore  is  to  be  credited  with  the  institution  of 


Fig.  32. — Sterile  Gloves  Packed  in  Peotectwe  Outer  Wrapper. 

this  method,  for  it  was  he  who  first  suggested  it  in  1889.  The  fact  that 
gloves  are  worn  must  not  cause  one  to  feel  oversecure  or  conclude  that 
their  protection  permits  a  slighting  of  the  enumerated  details  of  hand 
sterilization.  A  rubber  glove  torn  or  punctured  should  be  immediately 
replaced  by  a  perfect  glove.  While  their  preparation  and  care  occasion 
extra  work  for  the  nurse,  they  should  certainly  be  worn.  Dry  gloves  are 
preferable  to  wet  ones,  for  wet  gloves  soon  cause  the  fingers  to  become 
sodden  like  those  of  a  washerwoman,  and  the  delicacy  of  the  touch  is  lost 
or  impaired. 

Scrubbed,  gowned,  and  gloved  by  these  methods,  one  may  consider 


METHODS    or    HAND    STERILIZATION  57 

himself  as  properly  prepared  to  participate  in  an  operation,  provided  the 
steps  of  preparation  that  have  been  advanced  have  been  faithfully  and 
conscientiously  enacted.  Hands  may  be  made  sterile,  but  they  will  not 
remain  so  unless  we  are  constantly  alert  to  keep  them  so. 

The  scrubbed  nurse  must  ever  guard  against  coming  in  contact  with 
anything  that  is  not  sterile.  When  not  engaged  in  active  work,  the  hands 
should  be  held  above  the  level  of  the  waistline.  They  are  to  be  kept  clean 
by  washing  in  a  basin  containing  a  potent  antiseptic,  followed  by  rinsing 
in  sterile  water  as  frequently  as  they  are  badly  soiled  with  blood  or  wound 
secretions.  Some  operators  go  to  the  extent  of  covering  their  rubber 
gloves  with  sterile  cotton  ones  until  the  abdomen  is  open  and  then  remov- 
ing them.  This  is  partly  to  protect  the  rubber  gloves  from  soiling  before 
the  intra-abdominal  work  is  undertaken.  If,  perchance,  one  does  acci- 
dently  touch  an  unsterile  object,  the  glove  or  gloves  are  immediately 
removed  and  a  fresh  pair  put  on.  In  gynecological  surgery  where  both 
vaginal  and  abdominal  work  is  done,  fresh  gloves  are  put  on  when  trans- 
ferring from  one  field  to  another.  Added  security  is  attained  if,  just 
before  putting  on  the  second  pair  of  gloves,  the  hands  are  run  through  the 
hand  solutions.     The  gowns  are,  of  course,  always  changed. 

It  is  an  excellent  step  in  technique  for  the  nurse  to  wear  two  pairs  of 
gloves  while  giving  the  field  its  final  preparation  and  draping  the  patient, 
and  then  remove  the  outer  pair  when  all  is  in  readiness.  Thus  will  she 
be  provided  with  a  clean  pair  of  gloves  when  the  real  operative  work  is 
begun.  If  two  operations  are  to  be  performed  upon  different  patients 
in  the  same  home,  we  must  necessarily  go  through  all  the  steps  of  hand 
preparation  for  each  case. 

The  recommendations  and  methods  proposed  and  described  in  this 
chapter  are  commended  with  the  caution  that  the  mere  knowledge  of  these 
facts  is  insufficient.  To  accomplish  the  most,  they  must  be  understand- 
ingly  and  systematically  applied.  This  may  be  accomplished  in  the  high- 
est degree  only  after  repeated  reflection.  The  subject  demands  one's  close 
attention  and  study.  Develop  an  aseptic  conscience  and  remember  at  all 
times  that  you  become  an  accomplice  if  a  fatal  termination  may  be  traced 
to  your  acts  of  omission  or  commission  while  preparing  to  enact  a  part  in 
any  surgical  operation. 


CHAPTER  IV 

THE  PREPARATION  OF  THE  PATIENT 

Of  all  the  preparative  work  essential  to  a  surgical  operation,  no  pro- 
cedure is  more  difficult  or  more  diversified  than  the  preparation  of  the 
patient.  The  nurse  is  necessarily  compelled  to  correlate  her  efforts  in  such 
a  way  that,  when  the  task  is  completed,  the  entire  procedure  centers 
around  one  point — complete  asepsis. 

To  secure  in  this  task  a  thorough  course  of  procedure,  one  is  compelled 
to  devote  to  it  constant  thought  and  study.  Daily  practice  and  frequent 
reviews  are  necessary  to  enable  the  nurse  to  carry  out  her  work  efficiently. 

None  of  the  methods  of  surgical  technique  has  changed  so  often  as  that 
of  preparing  the  patient.  One  rule  or  another  is  being  modified  from  year 
to  year.  Each  new  beam  of  scientific  light  creates  new  conditions,  and  we, 
perforce,  must  adapt  ourselves  and  our  work  to  comply  with  the  require- 
ments of  more  recent  knowledge.  The  tendency  is  to  do  away  with  the 
elaborate  and  time-consuming  methods  of  the  past  whenever  it  has  been 
satisfactorily  demonstrated  that  a  simpler  technique  is  equally  efficient 
and  reliable.  It  is  only  by  constant  study  and  practice  that  we  are 
enabled  to  adapt  ourselves  and  our  work  to  the  latest  demands  of  surgery. 

GENERAL  OR  CONSTITUTIONAL  PREPARATION 

As  all  surgical  work  is  occasioned  by  abnormal  physical  conditions, 
arising  either  as  emergencies  or  as  the  result  of  a  gradually  developing 
pathology,  it  will  be  perceived  that  the  general  preparation  of  the  patient 
will  be  varied,  according  to  the  amount  of  time  allowed. 

Every  individual  submitting  to  surgical  interference  and  its  resulting 
confinement  in  bed  for  a  longer  or  shorter  period  of  time,  should  spend 
from  at  least  twenty-four  to  thirty-six  hours  in  bed  in  preparation  for  the 
ordeal.  The  advantages  of  such  a  preparatory  rest  have  received  con- 
siderable discussion,  and  varied  opinions  have  been  expressed  regarding 


THE    PREPARATION    OF    THE   PATIENT  59 

this  requirement.  As  a  result,  some  surgeons  insist  upon  two  or  three 
days'  preHminary  rest  in  bed,  while  others  are  satisfied  with  but  twelve 
hours.  The  argument  advanced  by  the  latter  is  that  the  longer  a  patient 
is  confined  to  his  bed  the  lower  will  be  his  physical  resistance.  On  the 
other  hand,  those  favoring  a  longer  period  of  preoperative  preparation 
maintain  that  their  patients  come  to  the  table  in  better  condition  and, 
therefore,  are  better  able  to  withstand  shock,  thus  increasing  their  chances 
for  ultimate  recovery. 

The  preliminary  care  must  be  of  such  a  nature  as  to  secure  the  fol- 
lowing results: 

1.  Complete  emptying  of  the  intestinal  tract,  not  by  one  dose  of  a 
drastic  cathartic,  but  by  the  use  of  milder  drugs.  To  lowxr  the  physical 
resistance  by  means  of  a  violent  cathartic  is  to  defeat  the  purpose  of 
preparation. 

2.  A  normal,  or  as  nearly  normal  as  possible,  functioning  of  the 
kidneys. 

3.  Nourishment  and  elimination  kept  up  by  simple,  concentrated, 
bland  diet  and  an  abundance  of  water. 

4.  A  stimulation  and  equalization  of  cutaneous  circulation  and  elimi- 
nation by  means  of  baths  and  massage. 

5.  Accustom  the  patient  to  the  use  of  bedpans,  urinals,  and  douche 
pans. 

6.  That  mental  and  physical  condition  of  rest  which  tends  to  enable 
every  patient  to  resist  the  operative  procedure. 

If  these  are  desirable  features,  and  they  have  not  been  demonstrated 
otherwise,  it  is  unreasonable  to  assert  that  they  can  be  secured  in  the  brief 
space  of  twelve  or  eighteen  hours.  Consequently,  I  am  inclined  to  recom- 
mend from  twenty-four  to  thirty-six  hours  of  preliminary  preparation, 
so  that  the  patient  may  come  to  the  table  in  the  best  possible  physical 
condition. 

The  indications  for  operative  work  may  be  so  imperative,  however, 
that  the  general  physical  state  of  the  patient  may  be  considered  of  lesser 
moment  than  the  surgical  need,  and  operative  work  must  be  instituted  at 
once,  regardless  of  the  general  physical  findings.     This  is  the  only  excep- 


6o  SURGICAL   NURSING 

tion  to  the  rule.  At  all  other  times  we  should  endeavor  to  attain  the 
greatest  degree  of  physical  normality  and  function. 

Before  a  surgeon  recommends  an  operation,  he  should  give  due  con- 
sideration to  the  patient's  physical  state,  and  should  require  a  thorough 
examination,  including  a  careful  inspection  of  the  lungs,  heart,  and  elimi- 
nating organs,  together  with  such  laboratory  analyses  as  may  be  indicated. 
By  means  of  the  knowledge  thus  obtained,  the  surgeon  is  able  to  determine 
what  preoperative  treatment  will  be  required  to  enable  his  patient  to  come 
to  the  table  in  a  satisfactory  condition.  In  general,  the  following  pro- 
cedures should  be  observed. 

The  Teeth. — The  condition  of  the  teeth  merits  attention,  and  a  visit 
should  be  made  to  the  dentist  for  the  removal  or  filling  of  decayed  teeth 
and  treatment  of  diseased  gums.  The  teeth  should  be  as  perfect  as 
mechanical  skill  can  make  them!  Greater  comfort  for  the  patient  during 
the  post-operative  days  will  thus  be  secured.  Education  has  brought 
about  a  more  general  interest  in  the  care  of  the  teeth,  and  the  toothbrush 
is  in  common  use;  still,  the  majority  who  neglect  their  teeth  remains  large. 
Upon  assuming  charge  of  a  case,  therefore,  you  may  have  to  request  the 
patient  to  attend  to  the  care  of  the  teeth.  It  is  the  duty  of  the  nurse  to 
insist  upon  the  frequent  use  of  a  toothbrush,  either  with  or  without  a 
dentifrice. 

Stomach  and  Bowels. — When  placed  upon  an  operating  table  the 
patient  should,  as  a  rule,  have  no  digesting  food  in  the  stomach,  and  the 
large  intestine  must  be  empty.  This  does  not  imply  that  patients  must 
be  starved,  nor  does  it  mean  that  they  are  to  be  subjected  to  the  action  of 
drastic  purgatives.  The  plan  usually  adopted  consists  of  a  course  of 
calomel  forty-eight  hours  previous  to  operation,  followed  by  a  saline. 
On  the  day  following  the  use  of  calomel  and  preceding  the  operation,  one 
ounce  of  castor  oil  should  be  given,  usually  at  4  p.m.;  on  the  following 
morning  (the  day  of  the  operation)  one  or  two  enemas  are  given.  This 
treatment  will  produce  a  satisfactory  emptying  of  the  intestinal  tract. 
When  rectal  or  vaginal  work  is  to  be  done,  or  in  work  upon  the  stomach, 
it  is  imperative  that  the  colon  be  entirely  empty.  The  nurse  must  be 
certain  that  all  of  the  enema  has  been  expelled.     Nothing  is  more  annoying 


THE    PREPARATION    OF    THE    PATIENT  6l 

or  indicative  of  carelessness  on  the  part  of  the  nurse  than  to  ha\^e  the  work 
of  the  surgeon  delayed  or  interfered  with  by  reason  of  bowel  movements 
and  the  soiling  of  drapings  in  the  midst  of  an  operation. 

For  two  or  three  days  previous  to  operation,  the  patient's  diet  should 
consist  of  bland  and  nutritious  food,  without  bulk,  and  he  should  be 
encouraged  to  drink  an  abundance  of  pure  water — at  least  a  glass  every 
two  hours,  to  wathin  one  or  two  hours  before  the  operation.  The  evening 
meal  on  the  day  before  the  operation  should  be  light,  consisting  of  broth, 
toast,  soft-boiled  egg,  and  milk  or  tea.  A  cup  of  broth  or  milk  at  nine  and 
twelve  o'clock  at  night  is  permissible.  If  the  operation  is  planned  to  take 
place  late  in  the  morning  or  early  afternoon,  broth  and  toast  may  be 
served  for  breakfast,  A  safe  rule  to  follow  is  to  give  no  nourishment  for 
six  hours  previous  to  the  administration  of  the  anesthetic.  In  operative 
work  on  the  stomach  at  least  ten  hours  should  elapse  after  the  last  taking 
of  food. 

The  Kidneys. — Even  though  the  surgeon  or  the  attending  physician 
may  have  made  a  urinalysis,  a  specimen  of  urine  should  be  obtained  and 
given  to  the  surgeon  or  physician  at  the  time  of  his  visit  on  the  day  before 
operation.  From  a  female  patient,  the  specimen  should  be  (Obtained  by 
catheter. 

The  object  of  securing  a  specimen  of  urine  is  to  determine  the  state 
and  activity  of  the  kidneys.  Kidney  disease  or  deficient  kidney  secretion 
ma}^  at  times,  cause  all  operative  undertakings  to  be  either  postponed  or 
abandoned  entirely.  The  presence  of  sugar,  albumin,  casts,  acetone, 
diacetic  acid,  or  marked  indican  reaction  in  the  urine  of  the  patient, 
as  a  rule,  should  cause  the  postponement  of  all  but  emergency  operations. 
The  presence  of  albumin  alone,  with  an  absence  of  granular  or  fatty  casts, 
does  not  necessarily  indicate  a  serious  kidney  lesion.  It  should  put  the 
surgeon  on  his  guard,  however,  and  influence  him  in  the  selection  of  the 
anesthetic  agent. 

Baths. — During  the  preparative  rest  in  bed  two  or  three  sponge  baths 
a  day  may  be  given  advantageously,  followed  by  a  general  massage  and 
rub  with  alcohol  or  cocoa  butter.  This  will  increase  the  cutaneous  circula- 
tion and  elimination  and  also  be  restful  and  comforting  to  the  patient. 


62 


SURGICAL   NURSING 


On  the  morning  of  the  operation  the  bath  should  be  given  not  later  than 
two  hours  before  the  time  set  for  the  surgeon  to  commence  his  work. 
Under  no  circumstances  should  the  nurse  include  the  field  of  operation 
in  thig  last  preoperative  bath. 

The  Night  before  Operation. — The  patient  should  eat  a  light  supper, 
as  previously  suggested.  A  warm  sponge  bath,  followed  by  an  alcohol 
rub,  should  be  given  at  about  nine  o'clock,  and  the  field  of  operation  pre- 


FiG.  33. — Surgical  Leggings. 

pared  according  to  the  surgeon's   orders.     If  no  other  instructions  are 
given,  the  field  should  be  shaved. 

The  ordeal  that  he  is  to  undergo  on  the  following  morning  often  causes 
the  patient  to  be  more  or  less  restless,  and  he  finds  it  difficult  to  fall  asleep. 
At  least  six  or  eight  hours  of  continuous  slumber  should  be  secured  if 
possible.  The  nurse  will  find  that  the  bath  and  rub,  followed  by  a  cup  of 
hot  milk,  will  frequently  be  sufficient  to  induce  sleep,  especially  if  the  house 
is  quiet  and  an  abundance  of  fresh  air  is  admitted  to  the  room.  A  tactful, 
reassuring  nurse,  with  a  timely  word  and  an  encouraging  smile,  can  do 
much  to  maintain  a  quiet  mental  attitude  in  her  patient.  Secure  the 
confidence  of  your  patients;  be  frank  and  open  with  them.     Do  not  tell  a 


THE   PREPARATION   OF    THE   PATIENT  63 

falsehood  in  reply  to  a  patient's  question,  no  matter  how  good  your  in- 
tention may  be. 

SCHEDULE  OF  PREOPERATIVE  PROCEDURE 

The  following  schedule  of  work  for  the  day  previous  to  the  operation, 
if  it  is  to  take  place  in  the  home,  is  submitted  as  a  suggestive  outline  of  the 
nurse's  activities.     It  must  necessarily  be  altered  in  given  cases. 

A.M. 

7:00     Bath  and  general  rub. 

7:30     Breakfast. 

8:00     Instruct  servants  or  assistants  to  dismantle  room  selected  for  operation 

and  clean  it. 
9:00     Begin  preparation  of  operating  room. 
10:00     Cup  of  broth  or  milk. 

11:00     Calomel,  grains  2  or  5,  if  such  is  surgeon's  order. 

12:00     Operating  room  preparation  complete.     During  morning  patient  has  been 
given  several  glasses  of  water. 
P.M. 
12:30    Lunch. 
1 :30     Seal  operating  room  and  fumigate  it.     Patient  induced  to  take  nap. 
2:30     Sterilize  utensils  and  arrange  for  hot  and  cold  sterile  water. 
4:00     Effervescent  citrate  of  magnesia,  or  a  saline  cathartic  if  the  patient  has 
taken  calomel.     If  calomel  has  not  been  administered,  give  castor  oil, 
I  ounce. 

5  :oo     Soapsuds  enema. 

6  :oo    Light  supper. 

7 :30     Open  operating  room  for  airing. 

8:00     Enema,  douche,  shave  field,  general  bath,  and  rub.     Make  comfortable 

for  night.     Glass  of  hot  milk. 
9:30     Patient  asleep;  abundance  of  fresh  air. 
12:00     If  patient  is  awake,  cup  of  hot  broth  or  milk  is  given. 

A.M. 

5  :oo     If  awake  give  a  cup  of  broth. 

6 :3o     General  bath,  rub,  enema,  douche. 

7:30     Hypodermic   of   morphin,   if   ordered;    put   on   leggings   and   headpiece. 

Catheterize. 
8:00     Ready  for  operation. 

If  the  operation  is  to  take  place  later  in  the  morning  the  suggested 
outline  may  be  changed  so  as  to  adapt  it  to  the  hour  selected. 


CHAPTER  V 
THE  PREPARATION  OF  THE  OPERATIVE  FIELD 

The  preparation  of  the  field  of  operation  calls  for  as  careful  and  pains- 
taking technique  as  the  preparation  of  the  surgeon's  and  nurse's  hands. 
The  methods  employed  have  been  varied  from  time  to  time.  Present-day 
methods  are  characterized  by  their  simplicity.  It  was  but  a  few  years 
ago  that  the  universal  technique  was  outlined  as  follows: 

On  the  afternoon  or  evening  previous  to  operation,  the  field  was  shaved 
and  a  soft  soap  poultice  applied  and  permitted  to  remain  from  one  to  two 
hours.  Then  followed  a  thorough  scrubbing  with  soap  and  water  with  the 
use  of  a  brush.  This,  in  turn,  was  followed  by  ether,  bichlorid,  and 
alcohol.  The  field  was  then  covered  with  sterile  dressings  maintained  in 
place  by  a  binder  or  bandage.  When  the  patient  was  placed  upon  the 
operating  table,  and  coincident  with  the  administration  of  the  anesthetic, 
the  final  steps  of  preparation  were  taken.  These  consisted  of  again 
scrubbing  the  field  with  soap  and  water,  followed  by  the  application  of 
ether,  bichlorid  and  alcohol.  The  preparation  was  then  considered 
complete. 

Today  this  method  has  been  simplified  and  the  general  practice  con- 
sists of  the  following: 

On  the  afternoon  or  evening  previous  to  the  day  of  operation,  the  field 
is  shaved  and  cleansed  by  means  of  a  simple  bath  of  soap  and  water.  No 
dressings  are  applied,  and  care  is  exercised  that  no  water  comes  in 
contact  with  the  field  within  six  hours  of  the  final  preparation. 

When  the  patient  is  placed  upon  the  table,  and  coincident  with  the 
administration  of  the  anesthetic,  the  field  is  exposed  and  surrounded  with 
sterile  towels.  By  means  of  a  sterile  gauze  sponge  held  in  a  sponge  holder, 
the  field  is  thoroughly  gone  over  with  pure  benzin  or  benzin-iodin  (iodin 
crystals,  i  part,  to  benzin,  i  ooo  parts) .  This  solution  of  benzin  is  permitted 
to  evaporate  thoroughly,  which  requires  about  two  minutes.     The  entire 


THE   PREPARATION    OF    THE    OPERATIVE   FIELD  65 

field  is  now  gone  over  again  with  a  50  per  cent,  tincture  of  iodin  in  alcohol. 
The  field  may  then  be  considered  sufficiently  prepared,  and  is  ready  for 
its  final  draping. 

In  vaginal  work  the  vagina  is  cleansed  with  alcohol,  and  the  cervix 
and  mucous  membrane,  as  well  as  the  labia  and  surrounding  cutaneous 
surface,  are  painted  with  the  iodin  solution. 

In  rendering  this  final  preparation  to  the  skin  it  is  well  to  sterilize  an 
area  considerably  beyond  the  proposed  line  of  incision.  For  illustration, 
in  a  laparotomy  for  work  upon  the  pelvic  organs,  the  area  prepared  is 
bounded  by  a  line  across  the  abdomen  an  inch  above  the  umbilicus,  by 
a  line  extending  across  the  thighs  level  with  the  pubes,  and  on  either  side 
by  a  boundary  continuing  in  line  with  the  trochanter  of  the  femur.  A 
similar  area  is  prepared  when  the  work  is  being  done  in  the  upper  ab- 
dominal cavity.  It  is  better  to  prepare  too  large  a  field  than  too  small,  for 
the  exigencies  of  any  operation  may  demand  that  the  surgeon  extend  the 
incision  beyond  the  length  first  planned,  and  he  should  not  be  delayed  by 
being  compelled  to  wait  until  the  additional  field  is  sterilized. 

When  applying  the  benzin  and  iodin,  the  nurse  should  have  the  solu- 
tions in  small  sterile  basins  or  cups.  A  sterile  sponge  is  folded  and  held 
in  a  sponge  stick.  The  benzin  is  first  applied  to  the  umbilicus.  This 
sponge  is  then  discarded.  A  fresh  sponge  is  put  into  the  holder,  and 
with  it  the  benzin  is  applied  to  the  remainder  of  the  field.  One  must 
remember  that  the  object  of  using  the  benzin  is  to  remove  all  cutaneous 
gland  secretion.  To  accomplish  this,  light  swabbing  is  ineffectual. 
Reasonable  force  and  friction  must  be  used. 

The  benzin  having  evaporated,  another  fresh  sterile  sponge  is  placed  in 
the  holder  and  the  iodin  is  applied  to  the  umbilicus.  This  sponge  is  then 
discarded,  and  with  a  new  one  the  iodin  is  applied  to  the  remainder  of  the 
field. 

In  executing  this  preparation  the  nurse  should  train  herself  to  do  it  in  a 
methodical  and  exact  manner.  After  the  navel  has  been  cleansed  with 
the  iodin  and  the  second  sponge  is  secured,  the  nurse  should  cause  the 
proposed  line  of  incision  to  receive  the  first  application  of  the  iodin  and 
then  constantly  work  away  from  the  site.     Never  paint  the  line  of  in- 

5 


66  SURGICAL  NURSING 

cision,  then  on  one  side  and  then  the  other,  finally  giving  the  line  of  incision 
a  last  "dab"  with  the  sponge,  but  apply  the  iodin  to  the  line  of  incision 
first,  and  then  avoid  touching  that  area  unless  a  new  sponge  is  secured. 
A  systematic  plan  is  to  cleanse  the  umbilicus,  then  discard  the  sponge, 
secure  a  fresh  sponge,  paint  the  line  of  incision,  paint  on  both  sides  of 
this  line,  and  then  paint  the  pubes  and  thighs. 

In  emergency  operations  the  preparation  of  the  field  consists  of  a 
thorough  cleansing  with  benzin,  after  which  iodin  is  employed  and  the 
drapings  adjusted.  Shaving  is  done,  of  course,  when  necessary,  but  no 
water  should  be  used. 

This  method  is  now  generally  employed  and  is  acknowledged  as  re- 
liably ef&cient.  There  are  some  surgeons,  however,  who  direct  that  after 
the  iodin  has  been  applied  the  field  be  gone  over  with  70  per  cent,  alcohol. 
A  few  operators  are  found  who  do  not  employ  the  iodin  but  are  content 
with  the  use  of  70  per  cent,  alcohol.  Here  and  there  one  will  also  find  a 
surgeon  who  remains  content  with  the  technique  of  several  years  ago. 

DRAPING  THE  FIELD 

The  operative  field  having  been  rendered  sterile,  the  patient  is  now 
ready  for  draping  with  sterile  sheets  and  towels,  which  are  so  placed  as  to 
expose  only  as  much  of  the  field  as  may  be  required  for  the  work  to  be 
performed.  Two  sterile  sheets  are  used,  one  above  and  one  below,  and 
these  should  be  sufficiently  large  to  cover  the  patient's  entire  body  and 
hang  well  down  over  the  edge  of  the  table.  The  edges  of  these  sheets 
nearest  the  field  are  further  protected  by  additional  towels,  or  small  sterile 
sheets,  so  that  there  remains  exposed  only  the  actual  surface  of  the  skin 
demanded  for  the  operative  attack.  The  towels  or  small  sheets  are  fas- 
tened in  place  by  means  of  safety  pins  or  towel  clamps  (Fig.  37). 

The  foregoing  technique  having  been  rigidly  observed,  the  surgeon 
may  now  begin  his  work,  provided  the  patient  is  in  a  stage  of  complete 
anesthesia.  If  the  stage  of  anesthesia  has  not  been  reached,  or  if  the 
surgeon  is  not  quite  ready  to  commence  the  operation,  it  is  desirable  that 
the  field  be  protected  with  a  folded  sterile  towel  until  the  actual  operative 
work  is  begun. 


THE   PREPARATION    OF    THE    OPERATIVE   FIELD  67 

POSITIONS  ON  THE  TABLE 

A  folded  towel  is  used  as  a  covering  for  the  patient's  head.  It  pro- 
tects the  hair  and  at  the  same  time  prevents  the  hair  from  annoying  the 
anesthetist.  The  leggings  (Fig.  ^^)  are  employed  as  a  means  of  providing 
added  comfort  and  warmth.  Whatever  rings  or  jewelry  the  patient  may 
have  been  accustomed  to  wear  are  to  be  removed. 

Because  of  the  possible  unconscious  movements  and  struggles  of  the 
patient  when  in  the  excitement  stage  of  the  anesthetic,  it  is  well  to  secure 
the  patient's  hands  and  limbs.     This  may  be  accomplished  in  several  ways. 


Fig.  34. — Patient  on  Improvised  Operating  Table. 
The  patient  is  dressed  in  a  short  nightgown  and  protective  leggings.     The  hair  is  completely 
covered  by  a  folded  towel.     The  hands  are  held  in  place  by  a  strap  buckled  around  the  wrist  and 
passed  under  the  patient's  body  to  the  other  wrist.     A  bandage  may  be  used  instead  of  the  strap. 
The  legs  are  held  in  place  on  the  table  by  a  surcingle. 

Usually  the  hands  are  tied  at  the  side  of  the  table  by  means  of  a  strap  (Fig. 
34),  a  gauze  bandage,  or  padded  leather  cuffs  that  come  as  a  part  of  the 
table  equipment.  In  fastening  the  hands,  care  should  be  exercised  that 
the  wrists  be  not  too  tightly  constricted  and  the  blood  supply  thus  in- 
terfered with.  Another  precaution  is  to  make  sure  that  the  elbows  do 
not  extend  over  the  edge  of  the  table;  if  they  do,  the  weight  of  the  arms, 
and  also  the  weight  of  the  surgeon  or  assistant  leaning  against  them,  causes 
considerable  pressure  upon  the  inner  sides  of  the  arms  against  the  sharp 
edges  of  the  table.  This  frequently  will  cause  a  paralysis  of  the  musculo- 
spiral  nerve,  which  may  become  permanent.  At  best  it  is  very  annoying 
because  it  mav  continue  several  weeks.     The  limbs  should  be  restrained 


68  SURGICAL   NURSING 

by  passing  a  surcingle  over  them  and  fastening  it  on  the  under  side  of  the 
table  (Fig.  34)  or  by  tying  the  ankles  to  the  foot  of  the  table  by  means  of 
gauze  bandages. 

Operative  work  in  different  regions  and  upon  the  various  organs  re- 
quires that  the  patient  be  placed  in  certain  definite  positions  upon  the 
table. 

Skull  and  Brain. — Work  in  this  region  calls  for  the  elevation  of  the 
head  to  an  angle  varying  from  twenty-five  to  forty-five  degrees.  The  po- 
sition is  obtained  by  placing  sandbags  under  the  patient's  shoulders,  neck, 
and  head,  if  the  elevation  cannot  be  secured  by  adjustment  of  the  operating 
table. 

Goiter. — In  order  that  the  thyroid  gland  may  be  thrown  forward  more 
prominently  and  to  put  the  muscles  of  the  neck  on  the  stretch,  a  sandbag 
is  placed  under  the  nape  of  the  neck  and  the  head  permitted  to  hang  over 
this  elevation  (Fig.  35). 

Breast  Amputation. — A  board,  six  or  eight  inches  wide  and  long  enough 
to  reach  beyond  the  arm  when  it  is  extended,  is  covered  with  a  sterile 
covering  and  placed  at  right  angles  with  the  table  and  under  the  patient's 
shoulder.  Upon  it  the  arm  is  extended  so  as  to  give  ample  exposure  of  the 
axilla.  In  preparing  this  field,  the  axilla  and  the  arm  halfway  to  the  elbow 
is  prepared.  The  remainder  of  the  arm  and  the  hand  is  covered  with  ster- 
ile towels  or  a  sheet,  or  is  enclosed  in  a  sterile  gauntlet. 

Gall-bladder  Operation. — In  order  that  the  gall-bladder  may  be 
thrown  into  closer  apposition  to  the  anterior  abdominal  wall,  a  sandbag 
is  placed  under  the  patient's  back.  Modern  tables  have  an  elevating 
attachment  to  secure  this  position. 

Kidney  Operations. — For  this  work  the  patient  is  placed  in  the  lateral 
prone  position,  and  the  kidney  to  be  operated  upon  is  thrown  more  into 
prominence  and  its  approach  simplified  by  placing  a  sandbag  under  the 
side  of  the  patient,  so  arranged  as  to  cause  an  elevation  of  the  kidney  area 

(Fig.  36). 

Trendelenbtirg  Position.- — This  position  is  required  in  practically  all 
operations  upon  the  pelvic  organs  approached  by  the  abdominal  route. 
By  means  of  this  position  the  bowels  fall  back  into  the  upper  abdomen  and 


THE   PREPARATION    OF    THE    OPERATIVE   FIELD 


69 


,    '       '    / 

'^ 

am 

imiiijii  nil./ 

^*«**... 

k 

•1 

'^ 

Fig.  35. — Preparation  for  Goiter  Operation. 
The  shield  of  sterile  cloth  stretched  over  a  wire  frame  prevents  the  patient's  mouth  and  the  anes- 
thetist's mask  from  contaminating  the  wound.     The  field  of  operation  is  clearly  shown.     A  sand- 
bag under  the  neck  elevates  the  field  of  operation,  which  is  draped  with  sterile  towels. 


Fig.  36. — Patient  in  Position  for  Kidney  Operation. 
The  patient's  right  arm  rests  on  the  far  side  of  the  table;  the  left  arm  is  behind  his  back  and  is  seen 
in  the  foreground  of  the  picture.  The  area  of  operation  is  raised  by  a  large  sandbag  under  the  pa- 
tient's waist.  This  view  shows  the  first  sterile  towels  in  place,  ready  to  be  covered  by  the  laparotomy 
sheet  and  the  final  towels.  The  lower  margin  of  the  exposed  field  of  operation,  which  wiYi  finally 
be  surrounded  by  sterile  towels,  is  indicated  by  the  dotted  line. 


70 


SURGICAL   NURSING 


thus  do  not  interfere  with  the  surgeon's  work.  The  position  is  secured  by 
elevating  the  feet  and  the  pelvis  of  the  patient  and  by  lowering  his  shoul- 
ders and  head  so  that  the  body  lies  at  an  angle  of  approximately  forty-five 


Fig.  2>1- — Patient  in  Trendeleistburg  Position. 

For  the  improvised  operating  table  a  kitchen  table  and  a  smaller  table  were  used.     The  lower  end  of 

the  kitchen  table  was  raised  on  blocks  to  give  a  better  elevation  for  the  Trendelenburg  position. 


Fig.  38. — Many-tailed  Abdominal  Bandage  in  Place  at  the  Completion  of  a  Laparotomy, 

degrees.  Operating  tables  are  constructed  so  that  the  patient  may  be 
thrown  into  this  position;  if  such  an  operating  table  is  not  used,  the  posi- 
tion may  be  secured  by  the  use  of  boards,  blocks,  or  chairs  as  depicted 

(Fig.  37)- 

The  true  Trendelenburg  position  is  one  in  which  the  feet  and  legs  are 


THE   PREPARATION   OF    THE    OPERATIVE   FIELD  7 1 

maintained  in  extension.  There  are  some  surgeons,  however,  who  drop 
the  feet  and  legs  over  the  end  of  the  elevation.  The  objection  to  this 
practice  is  that  the  flexing  of  the  legs  causes  a  rigidity  of  the  abdominal 
muscles,  which  cannot  be  relaxed  by  the  anesthetic.  In  this  event  the 
approach  to  the  pelvic  organs  must  be  made  through  a  rigid  abdominal 
wall. 

Vaginal  Work. — The  hips  are  brought  down  well  over  the  edge  of  the 
table  and  the  thighs  flexed  upon  the  abdomen.  The  lower  legs  are  flexed 
on  the  thighs  and  held  in  place  either  by  stirrups  and  holders,  or  by  a  sheet 
or  bandage  fastened  around  one  knee  and  passed  around  under  the  neck 
of  the  patient  and  fastened  to  the  other  knee. 

In  these  positions  the  draping  of  the  patient  is  carried  out  as  in  the 
more  common  positions^  and  the  draperies  so  placed  as  to  expose  only  as 
much  of  the  field  as  is  necessary. 


CHAPTER  VI 

DUTY  OF  THE  NURSE  DURING  OPERATION 

The  patient  anesthetized  and  the  surgeon  and  his  assistants  ready,  the 
time  is  at  hand  when,  for  a  period  of  from  fifteen  minutes  to  two  hours,  the 
surgical  nurse  will  be  called  upon  to  perform  certain  definite  duties.  The 
nature  of  these  duties  is  predetermined,  and  familiarity  with  them  will  do 
much  to  expedite  or  retard  the  surgeon's  work.  To  become  a  capable 
surgical  nurse  one  must  know  not  only  what  to  do  but  how  and  when  to  do 
it,  that  the  teamwork  which  is  demanded  and  which  should  be  enacted  in 
every  surgical  operation  may  not  be  disrupted. 

For  an  operation  to  proceed  in  an  orderly  manner  there  must  be  a 
definite  division  of  labor.  The  operation  and  all  its  attendant  factors 
must  at  all  times  be  subservient  to  the  surgeon,  upon  whom  rests  the 
responsibility  of  the  operation  and  of  all  the  acts  of  those  who  participate 
in  the  work. 

The  principals  engaged  in  the  work  are,  in  the  order  of  their  importance 
and  authority,  surgeon,  first  assistant,  anesthetist,  second  assistant,  third 
assistant,  surgical  supervising  nurse,  scrubbed  nurse  or  nurses,  unscrubbed 
nurse,  and  orderly.  For  effective  teamwork  this  is  a  sufficient  number  for 
an  operating  theater.  For  an  operation  in  the  home,  however,  the  num- 
ber of  assistants  must  necessarily  be  limited,  and  in  this  case  the  nurse 
may  be  called  upon  to  perform  some  of  those  duties  assigned  to  the  sur- 
geon's medical  assistant. 

The  Surgeon. — He  is  the  recognized  head  of  the  group  to  whom  all 
others  are  subservient  and  to  whom  they  must  accurately  and  conscien- 
tiously render  their  services.  It  is  he  who  directs  every  detail  of  the  work 
that  is  done. 

First  Assistant. — This  assistant  is  the  surgeon's  immediate  representa- 
tive and  the  one  who,  in  many  instances,  will  superintend  the  carrying 

out  of  the  surgeon's  orders  as  well  as  to  be  of  immediate  aid  to  him  in  each 

72 


DUTY    OF    THE   NURSE   DURING    OPERATION 


73 


step  of  the  operation.  He  anticipates  the  operator's  desires  and  needs. 
During  the  actual  operative  work  it  is  his  duty  to  direct  the  assistants  and 
nurses  and  indicate  to  them  what  is  required  from  time  to  time  as  the 
work  progresses.  To  him  is  frequently  delegated  the  work  of  the  final 
suturing  of  the  wound  and  the  application  of  the  dressings. 

Second  Assistant.^ — The  second  assistant  aids  to  the  extent  of  seeing 
that  the  required  instruments,  needles,  and  sutures  are  promptly  provided 


Fig.  39. — The  Operative  Group. 
Note  position  of  the  two  surgical  nurses,  one  on  each  side  of  the  table.     The  surgical  supervisor 

stands  in  the  right  foreground. 

for  the  surgeon  as  he  may  require  them.  He  holds  retractors  so  as  to 
better  expose  the  site  of  operative  attack  and  sponges  away  the  blood.  In 
general,  he  is  an  assistant  to  the  first  assistant. 

Third  Assistant. — This  person  acts  as  an  aid  to  the  other  two  assistants, 
or  he  may  assume  the  duty  of  the  first  surgical  nurse.  The  third  assistant 
performs  the  work  of  final  sterilization  and  draping  of  the  field. 

The  Anesthetist. — As  the  term  implies,  the  anesthetist  has  charge  of 
and  administers  the  anesthetic  selected  by  the  surgeon. 


74 


SURGICAL   NURSING 


Fig.  40. — Operative  Group.    Laparotomy. 


Fig.  41. —  Operative  Group.     Removal  of  Coccyx. 


DUTY    OF    THE   NURSE   DURING    OPERATION 


75 


Surgical  Supervisor. — This  assistant,  customarily  a  trained  nurse  who 
has  received  special  training  in  surgical  nursing,  is  in  direct  charge  of 
nurses  engaged  in  the  operation  and  is  held  responsible  for  their  work. 

The  first  and  second  clean  nurses  are  the  remaining  important  princi- 
pals in  the  operating  team.     It  will  be  the  object  of  this  chapter  to  enlarge 


Fig.  42. — Patient  Prepared  for  Laparotomy. 
The  instrument  tray  is  in  place  and  the  nurse  is  holding  the  scalpel  in  readiness  to  hand  to  the 
surgeon.     Notice  the  protecting  screen  between  the  patient's  head  and  the  operative  field.     This 
serves  as  a  barrier  to  prevent  contamination  of  the  operative  field  from  the  mouth  of  the  patient  and 
anesthetist. 


upon  their  duties  and  to  describe  in  detail  the  methods  whereby  they  may 
best  perform  their  duties. 

A  word  of  caution  as  to  a  nurse's  demeanor  and  manner  of  personal 
conduct  during  an  operation  may  not  be  amiss.  From  a  lay  viewpoint, 
submission  to  a  surgical  operation  is  a  serious  procedure.  Daily  famil- 
iarity with  surgical  work  has  a  tendency  to  render  a  nurse  somewhat 
callous  toward  the  feelings  of  those  less  familiar  with  surgical  procedures. 


76 


SURGICAL   NURSING 


To  circumvent  such  a  possible  attitude  the  nurse  must  constantly  strive 
to  conduct  herself  so  that  her  demeanor  throughout  the  entire  operation 
will  be  characterized  by  dignity.  The  laugh,  the  joke,  the  story,  or  a 
careless  light-hearted  attitude  should  never  be  indulged  in  by  a  nurse 
while  so  engaged.  This  does  not  imply  that  she  should  perform  her  duties 
with  a  mournful,  oversanctimonious  air  but  with  dignified  activity.  The 
nurse  should  speak  only  when  necessary  and  then  in  a  low,  distinct  tone. 


Fig.  43. — Instrument  Stand  with  Instruments  Arranged. 
Note  two  scalpels,  three  Mayo  scissors,  three  tissue  forceps,  four  Kelly  curved  hemostats,  three 
Mayo  curved  hemostats,  two  straight  Mayo  hemostats,  four  straight  Kelly  hemostats,  tAvo  sponge 
sticks  with  sponges,  two  clamps,  two  pairs  retractors,  a  blunt  dissector,  and  an  appendical  tucker. 


An  operation,  except  in  a  clinic,  is  not  characterized  by  conversation. 
The  best  teamwork  is  done  without  conversation.  Each  participant  is  so 
trained  as  to  anticipate  his  duty  without  waiting  to  be  directed.  The 
surgeon  only  is  privileged  to  speak  or  carry  on  a  conversation.  Remem- 
ber that  every  act  determines  the  nurse's  qualifications.  Let  your 
methods  reveal  training  and  perfection  as  well  as  a  dignified  demeanor. 
The  one  word  that  may  be  selected  to  describe  most  fittingly  the  work 
of  a  clean  nurse  is  anticipation.  She  must  be  ever  alert  to  perform  her 
duty  and  provide  promptly  for  any  emergency.     To  anticipate  the  wants 


DUTY    or    THE   NURSE    DURING    OPERATION  77 

of  the  surgeon  or  his  assistants  and  so  minimize  delay  and  annoying 
moments  of  waiting,  should  be  the  guiding  motive  of  her  technique. 

It  is  well  to  familiarize  yourself  beforehand  with  the  surgeon's  prefer- 
ences and  customs.  You  will  be  conserving  time  by  having  an  ample 
supply  of  needles  and  sutures  ready  for  his  immediate  use.  The  instru- 
ments are  to  be  arranged  in  classified  groups  and  so  placed  that  those  in 
most  frequent  use  will  be  within  easy  reach  (Fig.  43).  (See  also  Fig.  8, 
page  T,s.) 

The  following  is  a  practical  classification  of  instruments  by  groups: 

1.  Holding  or  seizing  instruments:  tissue  forceps,  tenacula,  and  retractors. 

2.  Cutting  instruments:  scalpels,  scissors,  chisels,  cutting  forceps,  mallet,  saws. 

3.  Control  of  hemorrhage:  artery  snaps,  clamps,  and  ligature  carriers. 

4.  Needles,  sutures,  and  needle-holders. 

5.  Special  instruments. 

In  considering  the  wo'rk  of  the  surgeon  and  while  assisting  him  one  must 
remember  that  his  operation  is  characterized  by  definite  steps,  and  that 
these  steps  exist  in  practically  every  surgical  procedure.  They  are,  first, 
cutting  through  the  overlaying  structures  to  expose  the  part  or  organ  to 
be  operated  upon.  To  do  this  the  surgeon  requires  scalpels,  scissors, 
tissue  forceps,  artery  forceps,  retractors,  and  sponges.  These  must,  there- 
fore, be  ready  and  supplied  to  him  as  required,  and  it  is  the  nurse's  duty  to 
see  that  they  are  at  hand. 

The  seat  of  the  lesion  that  called  for  surgical  interference  having  been 
reached  and  exposed,  the  nurse  anticipates  the  surgeon's  next  needs  by 
handing  to  him  or  to  his  assistant  such  instruments,  ordinary  or  special, 
as  may  be  required  to  complete  the  work.  For  illustration :  In  an  appen- 
dectomy, the  abdominal  cavity  being  opened,  the  nurse  should  have  in 
readiness  salt  blocks  or  packing  sponges  to  wall  off  the  remainder  of 
the  abdomen.  While  the  surgeon  is  delivering  the  appendix,  the  nurse 
prepares  a  ligature  for  tying  off  the  mesoappendix.  Next  she  has  ready 
the  intestinal  needle  threaded  with  silk  or  linen  for  the  purse-string  suture. 
This  is  followed  by  a  small  ligature  to  tie  off  the  stump  and  a  clamp  for 
clamping  the  distal  end  of  the  appendix.  The  scalpel  or  cautery  should 
be  in  readiness  for  severing  the  appendix,  and  also  the  "tucker."  While 
the  surgeon  is  returning  the  cecum  to  the  abdomen  and  picking  up  the 


78 


SURGICAL   NURSING 


peritoneum  preparatory  to  closing,  the  nurse  counts  her  sponges,  packs, 
clamps,  and  artery  forceps,  and  promptly  reports  whether  they  are  ac- 
counted for.     Then  she  hands  to  the  surgeon  the  needle-holder  which 


Fig.  44.— Standard  Make  or  Needle-holder.  Fig.  45.— Needle-holder  with  Large  Full- 

Proper    Way     to    Hold     in     Handing     to     curved    Needle    Threaded    with    Silkworm 
Surgeon.  Gut.      Forceps  Attached  eor  Tension  Suture. 

This  shows  the  proper  manner  of  holding  the  forceps  when  handing  to  surgeon.     Note  that  the  suture, 
when  threaded  in  needle,  is  twisted  two  or  three  times. 


Fig.  46. — Hagedorn  Saber-pointed  Needle  in  Needle-holder  and  Threaded  with  Catgut 
Ready  to  Hand  Surgeon  eor  Suturing  Muscle  or  Fascia. 

contains  the  needle  and  suture  for  closing  the  peritoneum.  Next  there 
are  in  readiness  several  silkworm-gut  sutures  (Fig.  45)  and  in  turn  the 
catgut  for  closing  muscle,  fascia,  and  skin  (Fig.  46).  Finally,  the  dressings 
are  given  to  the  assistant  for  covering  the  wound. 


DITTY    OF    THE   NURSE    DURING    OPERATION  79 

This  reveals  the  manner  in  which  the  alert  nurse  anticipates  the  needs 
of  the  surgeon.  Equal  proficiency  should  be  revealed  in  every  operation, 
whatever  its  nature. 

We  have  outlined  the  general  plan  of  work  of  the  scrubbed  nurse. 
There  are,  however,  certain  finer  points  that  a  nurse  must  observe  in  order 
that  she  may  secure  pronounced  efficiency  and  greater  definiteness  of 
purpose  in  her  operative  work.  Some  of  these  finer  points  of  technique 
are  acquired  naturally,  while  others  are  acquired  only  after  weeks  of  per- 
sistent study,  observance,  and  practice.  Persistent  attention  to  details 
will  alone  enable  her  to  possess  them.  While  they  may  be  described  to  a 
certain  extent,  it  is  impossible  to  give  specific  directions,  and  a  nurse  is 
therefore  compelled  to  resort  to  her  own  ingenuity  to  acquire  them  in  the 
performance  of  her  surgical  work.  So  far  as  possible  we  will  advance 
general  principles  and  suggestive  ideas  as  to  the  salient  features  of  this 
perfected  technique. 

INSTRUMENTS 

Be  sure  that  every  instrument  is  in  perfect  working  order;  if  it  is  not, 
discard  it. 

An  instrument  once  used  is  to  be  discarded,  provided  a  sufficient  num- 
ber of  the  same  kind  are  available. 

If  an  instrument  is  laid  down  and  the  surgeon  intends  to  use  it  later 
on  in  the  operation,  see  that  when  he  again  needs  it  all  stains  have  been 
removed.  This  may  be  accomplished  by  wiping  with  a  moist  sterile 
sponge. 

For  cutting  sutures  do  not  use  scissors  that  are  to  be  used  for  cutting 
tissue.  Have  one  pair  of  scissors  on  your  supply  table  for  your  suture 
cutting. 

Always  provide  at  least  six  artery  snaps  within  easy  reach  for  im- 
mediate use.  Let  the  close  of  operation  find  your  instrument  tray  and 
table  in  as  orderly  arrangement  as  when  operation  was  commenced. 
The  same  orderliness  should  be  maintained  during  the  entire  procedure. 

You  should  know  the  name  of  every  instrument  that  is  used.  It  will 
require  constant  study  to  possess  this  knowledge,  for  styles  and  forms  of 
instruments  are  constantly  changing. 


8o 


SURGICAL   NURSING 


Before  an  abdominal  incision  is  closed  be  sure  that  all  your  clamps  and 
artery  forceps  are  accounted  for. 

Instruments  held  in  reserve  should  remain  covered  with  a  sterile 
towel  until  called  into  use.     This  protection  should  never  be  omitted. 

SUTURES  AND  NEEDLES 

The  methods  of  suturing  most  frequently  used  are  the  continuous, 
glover's,  interrupted,  tension,  Lembert,  and  everting. 


1^ 


Fig.  47. — Continuous.       Fig.  48. — Glover's.         Fig.  49. — Interrupted.         Fig.  50. — Everting. 

Methods  of  Suturing  Wounds. 

The  continuous  is,  as  its  name  implies,  a  continuous  or  running  suture 
extending  the  entire  length  of  the  wound  (Fig.  47). 

The  glover's  is  a  continuous  suture  in  which  each  stitch  consists  of  a 
separate  binding  hitch  (Fig.  48). 

The  interrupted  is  one  in  which  each  stitch  consists  of  a  separately  tied 
suture  (Fig.  49). 

The  everting  is  so  placed  as  to  evert  the  raw  edges  of  the  wound  (Fig. 

50). 

The  tension  is  usually  of  silkworm  gut  and  is  interrupted.  To  prevent 
cutting  into  the  tissue  it  is  frequently  tied  over  a  roll  of  gauze  (Fig.  51). 


DUTY    OF    THE    NURSE   DURING    OPERATION  8 1 

The  Lembert  is  principally  used  in  intestinal  work.  The  suture  is 
carried  through  the  intestinal  wall  to  the  mucous  coat  and  outward  to  the 
surface  and  then  through  the  opposite  intestinal  wall  in  the  same  manner. 
It  is  then  tied. 


Fig.  51. — Tension  Suture  Tied  over  Roll  of  Gauze. 

Test  every  suture  before  threading  it  in  the  needle  (Fig.  52).  In  doing 
so  do  not  use  force  beyond  that  which  the  suture  is  supposed  to 
withstand. 


Fig.  52. — Testing  a  Ligature  Before  Handing  to  the  Surgeon. 

Catgut  sutures  may  be  made  more  pliable  by  immersing  in  alcohol  or 
by  dipping  for  a  moment  in  a  saline  solution.  Annoying  knots  and  tangles 
may  be  thus  prevented. 


82  SURGICAL   NURSING 

No.  I  catgut  is  of  ample  size  for  tying  small  bleeding  vessels.  No.  3 
is  of  sufficient  size  for  the  ordinary  larger  vessels.  No.  3  is  customarily 
used  for  tying  off  the  mesoappendix  and  in  tying  the  vessels  of  the  broad 
ligaments.  As  a  rule,  each  surgeon  has  a  preference  as  to  the  size  of 
suture  he  wishes  for  certain  uses  and  will  indicate  this  preference  before 
beginning  the  operation  if  you  ask  him. 

Needle  sizes  and  styles  to  be  used  will  vary  according  to  the  surgeon's 
custom.  Needles  are  usually  carried  in  his  instrument  kit.  The  nurse 
must  exercise  care  to  the  extent  that  every  needle  handed  to  the  surgeon  is 
sharp. 

Needles  threaded  with  silkworm  gut  should  have  a  forceps  attached. 

Needles  and  sutures  threaded  before  the  operation  should  be  protected 
with  a  sterile  towel. 

OPERATIVE  FIELD 

The  drapings  of  the  operative  field  may  become  badly  soiled  several 
times  during  the  course  of  the  operation.  The  nurse  must  ever  be  alert 
to  replace  soiled  drapings  with  clean  towels.  It  may  be  done  without 
interfering  with  the  work  of  the  surgeon  or  his  assistants.  Soiled  or  not, 
when  the  surgeon  is  ready  to  close,  the  field  should  be  surrounded  with 
fresh  towels. 

SPONGES  AND  PACKS 

Always  have  immediately  available  at  least  three  sponge  sticks  with 
sponges  (Fig.  53). 

Regulate  size  of  your  sponges  according  to  the  size  of  the  wound  and 
the  purpose  for  which  sponge  is  to  be  used. 

A  sponge  used  once  is  to  be  discarded  and  replaced  with  a  fresh  one. 

Accurately  ascertain  the  number  of  sponges  you  have  when  the  opera- 
tion is  commenced  and  have  some  one  check  your  count.  At  the  close  of 
the  operation  and  before  the  wound  is  sutured,  be  sure  that  every  sponge  is 
accounted  for  and  that  the  same  individual  checks  your  final  count.  This 
precaution  holds  true  of  packs. 

Walling-off  packs,  salt  blocks,  or  strips  are  used  either  moist  or  dry  as 
the  surgeon  prefers.     When  used  moist  they  are  wet  in  normal  saline  at  a 


DUTY   OF    THE   NURSE   DURING    OPERATION  83 


Fig.  53. — Sponge  in  Sponge  Stick,  Ready  to  Hand  to  Surgeon. 


Fig.  54. — ^Large  Sponge,  Uneolded. 


Fig.  55. — ^Large  Sponge  Folded  por  Use  as  a  Small  Sponge  in  the  Sponge  Stick, 


84  SURGICAL   NURSING 

temperature  of  ioo°.  Packs  covering  exposed  coils  of  intestine  should  be 
frequently  changed  so  that  the  bowel  does  not  become  chilled.  Attach  a 
forceps  to  every  pack  that  is  in  use  (Fig.  57).  Sponges  in  the  abdomen 
should  always  be  held  in  sponge  holders  or  have  forceps  attached  to  them. 


Fig.  56. — Gauze  Sponges. 
The  oblong  sponge,  used  either  on  or  off  a  holder  and  sometimes  called  a  wipe,  is  made  from  gauze 
which  measures  about  9  by  16  inches.     After  folding,  the  sponge  is  about  2  by  6  inches.     For  making 
the  square  sponge  used  in  the  sponge  stick,  a  piece  of  gauze  16  inches  square  is  required.     After  fold- 
ing, the  sponge  measures  4  by  5  inches.     To  make  the  small  sponge  use  gauze  9  inches  square. 

DRAINS 

The  kinds  of  drains  in  common  use  are : 

Gauze,  varying  from  a  half  to  four  inches  in  width  and  either  plain, 
iodoform,  carboHzed,  or  bichlorid.  The  plain  and  the  iodoform  are  the 
kinds  most  frequently  used.     They  are  made  in  yard  lengths  (Fig.  58). 


DUTY   or   THE    NURSE    DURING   OPERATION 


85 


Fig.  57. — Salt  Block  and  Packing  with  Clamps  Attached. 


Fig.  58. — Two-inch  Gauze  Drain  or  Packing. 
For  photographing,  the  drain  was  taken  from  a  sterile  package  and  one  end  unfolded  to  show  the 
width.     The  drain  is  cut  in  yard  lengths,  and  folded  back  and  forth  upon  itself  before  being  placed 
in  a  wrapper  for  sterilizing. 


86 


SimGICAL   NURSING 


Perforated  rubber  tubing  of  various  sizes  (Fig.  59), 

Split  rubber  tubing  within  which  are  placed  several  lengths  of  gauze 

(Fig.  59)- 

Cigarette  drain,  made  by  taking  several  strands  of  gauze  and  wrapping 
with  several  turns  of  gutta-percha  or  rubber  tissue  (Fig.  59).     Manufac- 


FiG.  59.- — Rubber  Drains. 
Perforated   rubber  tube,  split  rubber  tubing  with  several  lengths   of  gauze,   cigarette   drain   of 

rubber  tissue  ^^^th  gauze  inserted. 


Fig.  60. — Silkworm-gut  Drain. 

turers  now  supply  thin  rubber  tissue  of  several  sizes  so  that  it  is  only  neces- 
sary to  pull  the  gauze  through  this  thin  tubing.  This  avoids  the  necessity 
of  rolling. 

Silkworm-gut  drain,  consisting  of  ten  to  fifteen  strands  of  silkworm-gut 
sutures  (Fig.  60). 


DUTY    or    THE    NURSE    DURING    OPERATION  87 

DRESSINGS 

Various  solutions  and  powders  were  formerly  employed  to  bathe  or 
dust  over  the  wound.  As  a  rule  they  are  today  abandoned.  The  suturing 
completed,  the  skin  is  cleansed  from  blood  by  means  of  a  moistened  sponge, 
dried,  and  sometimes  painted  lightly  with  iodin.  Dry  dressings  of  gauze 
are  then  applied.     Some  seal  a  clean  wound  with  collodium. 


Fig.  61. — Dressing  Made  from  Piece  of  Gauze  8  ~by  20  Inches. 


Fig.  62. — Abdominal  Pad. 

The  gauze  so  used  is  cut  a  sufficient  size  to  amply  cover  the  wound. 
The  gauze  is  maintained  in  position  by  means  of  adhesive  strips,  tapes, 
binders,  or  bandages. 

ABDOMINAL  DRESSINGS 

Cover  the  wound  with  five  or  six  pieces  of  dressing  (Fig.  6i).  Place 
the  first  layers  on  each  side  of  the  incision  to  protect  the  skin  from  cut 


SURGICAL   NURSING 


ends  of  sutures  (Fig.  63).  Hold  in  place  with  inch  strips  of  adhesive  that 
fasten  the  upper  and  lower  ends  of  the  dressing  (Fig.  64) .  Cover  this  with 
an  abdominal  pad  (Fig.  62)  held  in  place  with  adhesive  tapes  (Fig.  65). 


V-,. 


Fig.  63.— First  Wound  Dressings.    Strips       Fig.  64. — First  Dressings,  Held  in  Place  by 
OF   Gauze  on  Each  Side  or  Incision  to  Keep  Strips  of  Adhesive. 

THE  Ends  of  Catgut  from  the  Skin. 


Fig,  65. — Abdominal  Pad  Held  by  Adhesive  Tapes. 


Cover  all  with  a  Scultetus  binder  (Fig.  67).  If  drainage  is  employed, 
fluff  gauze  around  the  drainage  material  and  do  not  apply  too  snug  a 
binder. 


Duty  of  the  nurse  during  operation 


89 


Dressings  of  the  head,  face,  chest,  or  extremities  are  maintained  in 
position  by  adhesive  or  bandages. 

Wounds  of  the  back  are  dressed  the  same  as  abdominal  wounds. 

In  major  amputations  see  that  the  stump  is  well  protected  by  a  suffi- 
cient quantity  of  dressings  and  cotton  pads. 


Fig.  66. — Scultetus  Binder. 

In  breast  amputations  the  axilla  should  be  well  padded. 

In  dressing  scalp  wounds  pad  back  of  the  ears  and  then  envelope  the 
entire  skull  with  a  roller  crown  bandage. 

If  splints  or  plaster  casts  are  used  always  provide  sufficient  padding 
over  bony  prominences  and  for  the  heel,  axilla,  and  popliteal  space. 


Fig.  67. — Scultetus  Binder  in  Place  at  the  Completion  of  a  Laparotomy. 

If  an  eye  is  to  be  covered  see  that  plenty  of  cotton  is  used. 

Never  leave  skin  in  contact  with  skin.  Always  provide  abundant 
padding. 

The  operation  completed,  the  final  dressings  in  place,  and  the  patient 
n  bed,  the  nurse's  first  duty  is  to  attend  to  the  preservation  or  disposal  of 


90  SURGICAL   NURSING 

the  pathological  specimen  or  part  that  was  removed,  according  to  the 
surgeon's  instructions.  This  done,  the  instruments  should  be  cleansed 
and  the  room  dismantled.  Of  course,  if  one  acts  in  the  dual  capacity  of 
surgical  nurse  and  nurse  to  the  patient  during  convalescence,  it  will 
often  be  impossible  to  leave  the  patient  immediately  to  perform  this  work. 
The  anesthetist  frequently  remains  with  the  patient  for  some  time  and, 
in  this  event,  the  opportunity  may  be  seized  to  begin  the  work  of  cleaning 
up. 

In  reviewing  your  work  as  a  surgical  nurse,  keep  in  mind  two  points: 
first,  to  anticipate  the  requirements  of  the  surgeon  and  his  assistants;  and 
second,  to  conduct  your  work  by  a  systematic  plan.  Time  is  required  to 
attain  an  advanced  degree  of  perfection,  and  the  nurse  must  ever  remain 
studious  and  active  in  keeping  herself  informed  regarding  the  most  recent 
developments  in  surgical  methods. 


CHAPTER  VII 

POST-OPERATIVE  NURSING  DURING  THE  FIRST  TWENTY-FOUR  HOURS 

The  operation  over,  dressings  and  bandages  in  place,  tlie  nursing  care 
given  a  patient  will  be  an  important  factor  in  determining  the  ultimate 
operative  result.  The  alert  attentive  nurse  can  do  much  to  influence 
favorably  the  patient's  convalescence  and  add  to  his  comfort. 

The  first  forty-eight  to  seventy-two  hours  will  be  the  most  trying  and 
demand  more  or  less  of  the  nurse's  time,  depending  upon  the  nature  of  the 
operation  and  the  anesthetic  employed.  The  patient  does  not  fully  rally 
from  the  depressing  systemic  effect  of  the  operation  and  reaction  is  not 
completely  established  until  the  second  to  the  fourth  day.  Patients 
often  speak  of  these  two  or  three  days  as  a  "dream"  and  recall  but 
indistinctly  what  transpired  or  how  they  conducted  themselves.  In 
spite  of  this  depression,  their  comfort  must  be  conserved  and  such  care 
administered  as  will  enable  them  to  pass  through  this  period,  which 
inaugurates  their  first  stage  of  return  to  health,  in  the  best  possible  manner. 

Before  returning  the  patient  to  bed  a  dry,  warmed,  fresh  nightgown 
should  be  put  on  him.  During  an  operation  a  patient  frequently  will 
perspire  profusely  and  his  gown  become  wringing  wet;  again  it  may  be- 
come soiled.  At  any  rate  he  is  to  be  robed  in  a  clean  gown.  Before  doing 
this  the  body  should  be  thoroughly  dried.  If  the  leggings  are  wet  or 
soiled,  they  are  to  be  changed.  The  patient  is  now  ready  for  bed.  The 
time  consumed  in  the  foregoing  work  should  be  as  brief  as  possible  and 
every  precaution  taken  to  prevent  chilling. 

The  Bed. — If  the  nurse  assisting  in  the  operation  is  to  assume  the 
after-nursing  of  the  patient,  she  will,  before  scrubbing  up,  arrange  for 
some  one  to  prepare  the  bed  according  to  her  directions  while  she  is 
engaged  in  assisting  the  surgeons. 

A  comfortable  bed  depends  upon  a  good  mattress  and  springs.  These 
should  be  covered  with  a  pad  and  a  waterproof  cloth  (Fig.  68).     These 

91 


92 


SURGICAL   NURSING 


in  turn  are  followed  by  a  sheet  and  a  drawsheet  (Fig.  69).  The  covering 
for  the  patient  consists  of  a  sheet,  a  woolen  blanket  or  comforter,  and  a 
spread.     Do  not  commit  the  error  of  using  several  heavy  blankets.     If 


Fig. 


-Mattress,  Mattress  Pad,  Protective  Rubber  Drawsheet. 


necessary  a  light  woolen  blanket  may  be  used  temporarily  over  the  spread. 
The  under  sheet  should  be  covered  with  several  hot-water  bottles  (Fig.  70) 


Fig.  69. — Under  Sheet  and  Drawsheet  in  Place,  Covering  Mattress  Pad  and  Protective 

Rubber  Drawsheet. 

and  the  covers  drawn  over  (Fig.  71)  so  that  the  bed  will  be  thoroughly 
warmed  before  the  patient  is  placed  therein. 

Unless  contraindicated,  the  patient  should  be  laid  upon  his  back. 
The  water  bottles  are  allowed  to  remain  in  the  bed,  but  the  nurse  must 


POST-OPERATIVE  NURSING  DURING  THE  FIRST  TWENTY-EOUR  HOURS      93 

be  alert  to  keep  them  at  least  ten  inches  from  the  patienfs  body.  Should 
unconscious  movements  or  tossing  occur  the  nurse  must  exercise  extra 
care  to  prevent  burns.     The  pillow  is  dispensed  with  during  the  first  few 


FtG.  70. — Bed  with  Hot-water  Bottles  in  Place.     Note  Rubber  Protective  Sheeting  and 

Towel  at  Head. 

hours  except  for  patients  with  spinal  deformity  and  the  shoulder  curva- 
tures of  advancing  age.     The  head  is  turned  to  one  side  and  rests  on  a 


Fig.  71. — Bed  Ready  for  Patient;  Warmed  and  Kept  Warm  with  Hot-water  Bottles. 

towel  covering  the  under  sheet.     A  vomitus  basin  and  two  or  three  towels 
must  be  within  easy  access. 

The  Room. — The  temperature  of  the  room  should  be  75°,  and  fresh 
air  supplied  in  abundance  but  not  directly  upon  the  patient.     A  bright 


94 


SURGICAL   NURSING 


light  should  not  be  admitted,  and  quiet  is  to  be  insisted  upon  throughout 
the  entire  house.     The  patient  must  not  be  left  alone  until  fully  conscious. 


Fig.  72. — Elevation  in  Abdominal  Drainage  Cases. 


A 


Fig.  73. — Elevation  Demonstrating  Pillow  Pinned  to  Bed  under  the  Buttocks  and  Pillow 

at  Foot  to  Prevent  Sliding. 

Elevation  of  the  Head  of  the  Bed. — In  operative  abdominal  work  in- 
volving the  pelvis  and  lower  abdomen  where  drainage  is  employed,  the 
head  of  the  bed  is  frequently  elevated  from  six  to  twenty-four  inches. 


POST-OPERATIVE  NURSING  DURING  THE  FIRST  TWENTY-FOUR  HOURS      95 

The  object  of  such  elevation  is  to  cause  fluids  and  pus  to  gravitate  to 
the  lower  abdomen  and  pelvis.  It  has  been  demonstrated  that  the  pelvic 
peritoneum  and  that  of  the  lower  abdomen  can  better  withstand  and  care 
for  infectious  organisms  than  the  upper  abdominal  peritoneum.  By- 
keeping  the  patient  in  an  elevated  position  spreading  peritonitis  is  limited 
in  a  vast  majority  of  instances.  Drainage  by  gravity  is  another  reason  for 
the  employment  of  this  position,  especially  in  vaginal  drainage  through 
the  posterior  cul-de-sac. 

The  position  is  secured  by  using  bricks  or  blocks  of  wood  under  the 
legs  of  the  head  of  the  bed  and  by  removing  the  casters  from  the  foot 
(Fig.  72).     Chairs  may  also  be  employed  for  this  purpose. 

To  overcome  the  tendency  of  the  patient  to  slide  to  the  foot,  several  de- 
vices are  recommended.  Of  all  such  devices  the  most  satisfactory  and  simple 
is  to  pin  a  pillow  securely  to  the  mattress  just  below  the  buttocks  (Fig.  73). 
A  foot  support  of  pillows  or  an  ordinary  footstool  is  an  additional  aid. 

Another  method  consists  in  the  use  of  a  cradle  sling  that  passes  below 
the  patient's  buttocks  and  is  fastened  around  or  to  the  headboard. 

The  elevated  position  is  maintained  for  a  period  of  three  to  fourteen 
days,  depending  upon  the  condition  that  indicates  its  employment. 
During  the  first  one  or  two  days  patients  frequently  complain  of  this 
unnatural  position.  They  soon  accustom  themselves  to  it,  however,  and 
experience  no  great  discomfort  or  loss  of  sleep. 

Fowler's  Position.^ — This  is  an  exaggerated  elevation  of  the  patient's 
head  and  trunk  so  that  he  assumes  practically  a  sitting  posture.  In 
this  position  the  patient's  body  is  supported  at  an  angle  of  slightly  more 
than  forty-five  degrees  by  a  back  rest  and  a  cradle  sling,  the  pelvis 
being  the  lowest  point.  Fowler's  position  is  indicated  in  peritoneal  in- 
fections where  drainage  is  used.  It  is  frequently  employed  in  stomach 
resections,  gastro-enterostomies,  intestinal  anastomoses,  and  in  peritonitis 
arising  from  any  source. 

Elevation  of  the  Foot  of  the  Bed. — This  position  is  secured  by  placing 
bricks  or  blocks  under  the  legs  of  the  footboard  and  raising  it  to  the  desired 
height.  A  pillow  is  placed  against  the  headpiece  to  prevent  discomfort  to 
the  patient's  head  from  resting  constantly  against  the  headboard. 


96  SURGICAL   NURSING 

Elevation  of  the  foot  of  the  bed  is  employed  in  shock  and  collapse  with 
severe  loss  of  blood.  The  position  is  contraindicated  if  drainage  of  the 
lower  abdomen  has  been  employed. 

The  employment  of  mechanical  restraining  devices  for  delirium  is  but 
a  confession  of  one's  lack  of  familiarity  with  modern  methods.  Delirium, 
even  of  severe  type,  may  be  readily  controlled  by  hydrotherapy  and 
elimination. 

A  patient  recovering  from  an  anesthetic  should  not  be  encouraged  to 
change  his  position  frequently  during  the  first  twelve  hours.  After  that 
time  he  may  be  allowed  to  lie  upon  either  side.  The  pain  in  the  wound 
occasioned  by  changing  to  a  new  position  may  cause  a  patient  to  object, 
but  his  objections  may  be  overcome  by  assuring  him  that  after  he  is  in 
the  new  position  the  wound  pain  will  immediately  disappear. 

One  of  the  most  trying  conditions  that  a  surgeon  and  a  nurse  have  to 
contend  with  is  the  patient's  complaint  of  post-operative  backache.  It 
is  the  result  of  two  causes,  the  patient's  position  on  the  table  and  the 
relaxation  of  the  spinal  muscles  produced  by  the  anesthetic.  While  on  the 
table  the  normal  curvature  of  the  spine  is  considerably  lessened  by  relax- 
ation of  the  support  offered  by  the  spinal  muscles.  This  throws  a  strain 
upon  the  intervertebral  ligaments  w^hich  reflect  the  strain  to  which  they 
have  been  subjected  by  causing  a  most  annoying  and  disturbing  backache, 
persisting  from  one  to  four  or  five  days. 

This  backache  may  be  prevented  or  greatly  lessened  by  having  the 
operating  table  covered  with  a  heavy  padding  six  to  eight  inches  in 
thickness.  We  are  accustomed  to  use  a  six-inch  hair  mattress  on  the 
operating  table,  and  its  prophylactic  effect  has  been  demonstrated  by  the 
patient's  freedom  from  this  distressing  backache.  Some  hospitals  have 
plaster  molds  to  support  the  hollow  of  the  back  and  so  relieve  these  liga- 
ments of  the  strain  to  which  they  would  otherwise  be  subjected.  The 
back  may  also  be  supported  with  pillows. 

When  this  condition  occurs  the  only  relief  that  can  be  secured  is  from 
massage  and  frequent  change  of  position.  Morphin  or  codein  is  indi- 
cated to  induce  sleep  and  thus  bring  relief  from  the  "ache." 

Following  an  abdominal  operation  the  extension  of  the  limbs  causes 


POST-OPERATIVE  NURSING  DURING  THE  FIRST  TWENTY-POUR  HOURS      97 

tension  upon  the  abdominal  recti  muscles,  which  produces  an  exaggera- 
tion of  the  pain  in  the  abdominal  incision.  It  may  be  relieved  by  elevat- 
ing the  knees  and  permitting  them  to  rest  on  one  or  two  pillows  (Fig.  74). 

In  amputations  of  limbs,  in  fractures,  or  in  other  operative  work  upon 
the  extremities  additional  comfort  is  secured  for  the  patient  if  the  involved 
limb  or  stump  be  elevated  by  means  of  a  pillow. 

In  passing  from  the  subject  of  the  patient's  bed  and  his  posture  therein, 
let  me  add  that  the  nurse  may,  by  many  little  attentions,  secure  additional 
comfort  for  the  patient.  Above  all,  keep  the  bed  clean,  the  covers  ar- 
ranged, and  a  general  appearance  of  tidiness. 


Fig.  74. — Tension  on  Abdominal  Muscles  Relieved  by  Elevation  of  Knees  over  Folded 

Pillow. 

Returning  Consciousness. — A  person  recovering  from  an  anesthetic 
should  not  be  left  alone  until  fully  conscious.  During  the  return  to 
consciousness  and  even  before,  the  relaxation  from  the  anesthetic  may 
cause  swallowing  of  the  tongue  or  a  dropping  of  the  jaw  (Fig.  75),  either  of 
which  will  cause  obstruction  to  breathing  and,  possibly,  asphyxiation. 

Again,  nausea  or  vomiting  may  be  attended  with  inspiration  of  the 
vomitus,  producing  laryngeal  spasm  with  serious  possibilities  of  choking, 
or  later,  of  inspiration  pneumonia.  Upon  the  patient's  return  to  bed  the 
mouth  is  to  be  cleansed  of  all  mucus,  and  the  head  turned  to  one  side.  The 
respiration  is  to  be  kept  free  from  all  obstruction. 

As  the  conscious  state  approaches  there  may  be  one  or  two  attempts  to 
vomit,  or  vomiting  of  stomach  contents  or  swallowed  mucus  may  occur. 
If  the  preoperative  preparation  has  been  thorough  and  the  anesthetic 


98 


SURGICAL   NURSING 


skillfully  administered  post-anesthetic  vomiting  will  be  much  lessened. 
In  spite  of  every  precaution  severe  vomiting  is  at  times  encountered. 
To  insure  greater  freedom  from  nausea  or  vomiting  some  anesthetists  are 
accustomed  to  perform  a  gastric  lavage  before  the  patient  leaves  the 
table  (Fig.  76).  If  this  practice  is  observed  a  stomach  tube,  a  mouth  gag, 
and  one  or  two  quarts  of  warm  normal  sahne  will  be  required.. 

If  vomiting  occurs  the  nurse  must  support  the  patient's  head,  holding 


Fig.  75. — Recovering  from  Anesthetic. 
Supporting  jaw  of  unconscious  patient.     Head  turned  to  side;  no  pillow,  towel  to  protect  bedding; 
additional  light  blanket  thrown  over  the  bed  for  added  warmth.     On  the  table  are  shown  hypodermic, 
glass  sterile  water,  sponges,  towels,  vomitus  basin. 

it  to  one  side,  and  with  a  sponge  or  towel  cleanse  and  free  the  mouth  of  all 
vomitus.  In  severe  retching  following  abdominal  operations,  pain  caused 
by  straining  may  be  lessened  by  supporting  the  abdomen  with  gentle 
pressure  of  the  open  palm  over  the  dressings. 

After  one  or  two  periods  of  vomiting  the  patient  will  continue  in  a 
semiconscious  state  and  be  more  or  less  listless.  If  he  should  attempt  to 
roll  or  toss  about,  he  should  be  restrained  by  reasonable  force. 

An  hour  having  elapsed,  the  patient  should  be  well  out  of  the  effects 
of  the  anesthetic.     These  first  moments  should  find  the  nurse  in  attend- 


POST-OPERATIVE  NURSING  DURING  THE  FIRST  TWENTY-POUR  HOURS      99 

ance,  for  her  presence  is  of  assuring  comfort  to  the  patient.  When  the 
patient  is  capable  of  understanding,  the  nurse  may  well  tell  him  that  the 
operation  is  over,  that  he  is  back  in  bed,  that  everything  progressed 
satisfactorily,  and  that  he  is  to  remain  quiet  and  endeavor  to  sleep. 

At  this  stage  the  patient  will  not  experience  much  if  any  pain,  as  the 


Fig.  76. — Gastric  Lavage. 
Requirements:  Two  pitchers,  vomitus  basin,  towels,  gauze,  stomach  tube,  mouth  gag,  jar.     Note 
protection  of  bed  with  towels  and  rubber  sheeting.     Patient's  head  brought  to  side  of  bed.     Nurse 
pouring  lavage  solution  into  stomach  tube. 

preanesthetic  opiate  and  the  anesthetic  still  serve  to  cover  sensibility  to 
pain.  The  patient  will,  if  encouraged,  fall  into  a  slumber  that  may  last 
from  one  to  two  or  more  hours. 

During  this  period  careful  watch  must  be  kept  of  the  pulse,  respiration, 
and  general  appearance.  After  the  lapse  of  one  or  two  hours,  failure  of 
returning  consciousness,  with  a  feeble,  rapid  pulse,  shallow  respiration, 


100  SURGICAL   NURSING 

and  pale  or  blue  appearance  warrants  prompt  institution  of  methods  of 
resuscitation.  The  only  exception  is  in  those  patients  who  have  had  one 
to  three  preoperative  doses  of  scopolamin  or  hyoscin  without,  or  combined 
with,  morphin.  Such  patients  may  sleep  for  six  to  eight  hours  after  an 
operation. 

After  a  slumber  varying  from  a  half  to  two  hours  the  patient  will 
complain  of  thirst  or  dryness  of  the  mouth  and  throat.  Formerly  water 
was  denied  for  twelve  to  twenty-four  hours.  Now  it  is  a  common  practice 
to  permit  drinking  of  small  quantities  of  water  at  frequent  intervals  pro- 
vided no  operative  work  upon  the  stomach  contraindicates  its  administra- 
tion. True,  the  water  first  taken  may  be  vomited  in  a  few  moments. 
This  is  really  to  be  welcomed  for  it  then  serves  as  a  gastric  lavage,  and  the 
water  subsequently  given  is  retained. 

If  vomiting  occurs  every  time  water  is  taken,  all  liquids  should  be 
withheld  until  the  stomach  is  capable  of  retaining  fluids.  Persistent  vomit- 
ing is  an  imperative  indication  to  withhold  all  fluids.  In  the  intervals 
the  patient  is  allowed  frequently  to  rinse  his  mouth  and  moisten  his 
lips.  -  Drugs  are  of  little  value  in  controlling  vomiting.  While  many 
and  various  measures  are  advanced  to  control  stomach  irritability,  the 
most  satisfactory  and  efficient  is  absolute  rest  of  the  stomach.  If  vomit- 
ing is  not  controlled  in  eight  to  twelve  hours  or  if  it  increases  in  severity, 
other  treatment  must  be  instituted.  The  condition  then  becomes  a 
surgical  emergency. 

The  patient  will  soon  begin  to  complain  of  being  in  an  uncomfortable 
position  or  of  a  tired  back.  A  pillow,  if  desired,  may  now  be  given  and 
added  comfort  secured  by  placing  a  pillow  under  the  knees.  Even  with 
this  attention  evidence  of  restlessness  will  again  soon  appear  and  endure 
for  a  period  of  time.  The  patient  will  ask  as  to  details  of  the  operation. 
He  may  become  very  talkative ;  fretting,  or  even  hysterical  manifestations 
may  be  shown.  It  is  well  for  the  nurse  to  analyze  her  patient's  actions 
and  to  endeavor  to  control  them  by  encouragement  and  reasoning. 
Familiarity  with  a  patient's  disposition  will  be  of  value  in  meeting  these 
conditions. 

Pain  and  Rest. — After  a  lapse  of  a  few  hours  the  pain  occasioned  by 


POST-OPERATIVE  NURSING  DURING  THE  FIRST  TWENTY-FOUR  HOURS    lOI 

the  wound  will  become  evident.  In  some  patients  the  pain  is  severe, 
while  in  others  it  will  occasion  little  or  no  comment.  If  the  restlessness 
and  pain  are  mastering  the  patient  it  is  justifiable  to  administer  the  ordered 
morphin  in  dosage  of  an  eighth  to  a  quarter  grain  hypodermatically. 
One  should  never  permit  a  person  to  suffer  unnecessarily.  Morphin 
should  be  administered  judiciously;  it  prevents  exhaustion,  conserves 
strength,  and  induces  beneficial  rest.  Usually  the  indications  will  be  to 
repeat  the  dose  in  four  to  six  hours  and  again  in  the  evening  and  possibly 
toward  morning.  Do  not  give  it  unless  indicated,  but  when  indicated  do 
not  hesitate  to  give  it.  Of  course,  we  realize  that  it  has  a  constipating 
effect  and  may  cause  subsequent  meteorism  and  difficulty  in  moving  the 
bowels,  but  if  employed  with  judgment  these  objections  may  be  ignored. 
Codein  is  sometimes  substituted.  One  must  remember  that  codein  will 
produce  rest  but  has  little  effect  on  real  pain,  and,  even  if  used,  one  will 
have  to  resort  to  morphin  to  attain  the  desired  effect.  Codein  may  well 
be  employed  after  the  second  day  if  such  a  remedy  is  required  and  simpler 
measures  are  unavailing. 

Frequent  bathing  of  the  hands  and  face  with  cool  water  produces 
relaxation  and  comfort.  Toward  afternoon  and  in  the  evening  an  alcohol 
rub  will  be  refreshing.  A  cold  compress  placed  over  the  forehead  and  eyes 
is  often  agreeable.  One  should  not  neglect  to  change  or  shake  up  the 
pillows  frequently  and  secure  a  change  of  the  patient's  position. 

Catheterization. — One  need  not  worry  or  become  anxious  because  the 
patient  does  not  express  a  desire  to  urinate  during  the  first  eight,  ten,  or 
twelve  hours.  Some  will  even  go  for  a  longer  period  without  danger  or 
discomfort.  As  a  rule,  the  patient  is  to  be  urged  to  urinate  in  ten  or 
twelve  hours.  If  unable  to  urinate  and  no  discomfort  is  expressed,  a 
patient  may  be  permitted  to  go  several  hours  longer  before  catheterizing. 
The  only  exception  to  this  rule  is  in  hysterectomies  and  bladder  operations, 
when  the  bladder  must  not  be  permitted  to  become  distended.  Kidney 
secretion  is  always  diminished  during  the  first  twenty-four  hours. 

Nourishment. — In  addition  to  the  water  that  is  given  the  patient  to 
drink  but  little  nourishment  is  to  be  permitted.  Toward  late  afternoon  or 
evening  a  cup  of  plain  hot  tea  will  do  no  harm  and  will  be  grateful.     It 


102 


SURGICAL   NURSING 


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Nurse's  Clinical  Record.    First  Day's  Record  of  an  Operati\'e  Case. 


POST-OPERATIVE  NURSING  DURING  THE  FIRST  TWENTY-FOUR  HOURS    IO3 


m 


may  be  repeated  later  on  in  the  evening.  A  glass  of  orange  or  lemon  albu- 
min may  also  be  administered.  On  the  whole,  nourishment  should  not  be 
urged  and  when  desired  or  requested  it  is  to  be  given  in  guarded  quantity. 
An  abundance  of  water  is  all  that  is  really  indicated  at  this  time.  Above 
all  things  be  sure  that  you  understand  the  surgeon's 
orders  regarding  water  and  nourishment,  and  if  they 
are  not  clear  ask  him  to  give  you  explicit  instruc- 
tion as  to  what  course  you  are  to  pursue. 

Salines. — It  is  customary  to  order  a  normal 
saline  by  the  rectum  during  the  first  twenty-four  to 
forty-eight  hours  in  all  major  operations.  This 
procedure  is  not  dependent  upon  the  patient's 
general  condition  as  an  indication  for  its  admin- 
istration. It  is  becoming  more  and  more  a  routine 
measure  of  considerable  merit,  as  it  supplies  the 
body  with  necessary  fluid  and  has  a  beneficial 
general  systemic  influence.  It  may  be  administered 
by  a  continuous  drop  proctoclysis  (Fig.  77)  or  in 
quantities  at  stated 
intervals. 

A  satisfactory 
method  is  to  admin- 
ister eight  to  twelve 
ounces  as  soon  as  the 
patient  is  placed  in 
bed  and  repeat  every 
six  hours.  The  pre- 
caution to  be  ob- 
served is  not  to  ad- 

FiG.  77. — Apparatus  for  Continuous  Proctoclysis  (Murphy  Drip). 
This  apparatus  consists  of  an  especially  constructed  glass  nozzle  through  which  the  drops  can  be 
seen,  a  screw  compressor  above  the  glass  nozzle  for  regulating  the  rapidity  of  the  drops,  a  return- 
flow  tube  which  is  attached  to  the  solution  container  by  a  glass  U  tube  for  the  escape  of  gas  from  the 
bowels,  a  glass  Y  tube  for  attaching  the  solution  tube  and  the  return-flow  tube,  and  a  metal  solution 
heater  which  rests  upon  the  bed.  A  felt  cover  is  provided  for  the  heater  when  in  use,  but  for  the 
photograph  it  was  removed  to  show  how  the  tubing  passes  through  the  metal  heater. 


I04  SURGICAL   NURSING 

minister  a  larger  quantity  at  one  time  in  hysterectomies  or  in  plastic 
work  upon  the  vagina  or  rectum,  even  though  a  patient  may  be  able  to 
retain  such  larger  quantities.  When  the  patient  can  take  large  quantities 
of  water  by  mouth,  the  rectal  salines  may  be  discontinued. 

Medication. — Very  little  medication  will  be  indicated  during  the  first 
day.  Strychnin,  grain  yio,  is  almost  always  ordered  to  be  given  hypo- 
dermatically  every  three  or  four  hours.  It  serves  to  keep  up  general 
systemic  tone;  further  than  that  it  is  of  but  little  value.  Digitalin  is 
ordered  by  some  surgeons.  If  a  cardiac  stimulant  or  support  is  indicated, 
the  most  satisfactory  remedies  are  camphor  oil  and  whiskey. 

If  the  patient  perspires  freely  and  continues  to  do  so,  atropin,  grain 
K50  to  H55  is  administered  to  prevent  the  loss  of  water  from  the  system. 

Temperature. — In  normal  recoveries  the  temperature  receives  but 
little  consideration  during  the  first  day.  It  is  well  to  record  it  at  three- 
hour  intervals  commencing  at  three  or  six  in  the  afternoon.  A  rise  in 
temperature  of  one-half  to  two  degrees  m.ay  be  recorded  during  the  first 
or  second  day  without  occasioning  alarm.  In  wounds  that  are  not  drain- 
ing, a  temperature  of  104°  or  over  should  be  reported. 

After  draining  abscesses  or  in  removing  decomposing  remnants  of 
impregnation  from  the  uterus,  the  patient  may  experience  a  severe  chill 
from  two  to  six  hours  after  her  return  to  bed.  This  chill  may  last  from 
fifteen  minutes  to  one  or  two  hours,  and  may  be  followed  by  a  rapid  rise  in 
temperature  so  that  shortly  after  the  chill  a  temperature  of  103°  to  105^^° 
may  be  recorded.  The  condition  is  caused  by  absorption  through  new 
avenues,  occasioned  by  the  operation;  as  a  rule  the  temperature  will  drop 
to  near  normal  in  a  few  hours. 

If  patients  suffer  from  chill,  they  should  be  covered  with  warm  blankets 
and  surrounded  with  hot-water  bottles.  A  hot  drink  is  also  indicated. 
The  chill  passed,  the  rising  temperature  after  it  reaches  i033>'^°  is  to  be 
controlled,  if  persistent,  by  tepid  sponging.  In  certain  instances  the 
invasion  of  the  general  system  by  this  sudden  inpouring  of  toxic  products 
will  occasion  serious  and  alarming  heart  action  and  collapse.  In  this 
event  active  stimulation  with  whiskey,  camphorated  oil,  and  normal  salines 
must  be  promptly  employed  to  overcome  the  depressing  effect. 


POST-OPERATIVE  NURSING  DURING  THE  FIRST  IWENTY-POUR  HOURS    105 

Pulse. — The  pulse  is  oar  best  indicator  of  the  patient's  condition. 
Close  study  of  the  pulse  will  impart  reliable  information  and  tell  us  what 
may  or  may  not  be  necessary.  Volume,  rhythm,  character,  and  rapidity 
must  be  noted  when  taking  the  pulse. 

A  pulse  of  small  volume  and  strength  must  be  watched.  If  its  char- 
acter does  not  improve  in  a  reasonable  length  of  time  suitable  treatment 
should  be  promptly  instituted.  This  same  caution  should  be  observed  in  a 
full,  bounding  pulse  of  high  tension.  An  irregular  rhythm  must  also 
receive  the  nurse's  careful  watching. 

The  rapidity  of  the  pulse  is  of  less  moment  provided  it  is  of  good 
volume,  character,  and  rhythm.  A  pulse  of  80  before  operation  may  rise 
twenty  or  thirty  beats  without  creating  any  concern.  A  pulse  that 
registered  100  before  operation  may  be  counted  at  120  or  130  afterward 
and  remain  so  for  several  hours  without  exciting  the  least  alarm.  As  a 
rule,  a  post-operative  rise  of  pulse  of  twenty  to  thirty  beats  and  its  per- 
sistence for  two  or  three  hours  is  a  normal  occurrence.  Usually  it  will 
become  gradually  less  rapid  and  fall  within  bounds  after  the  lapse  of  an 
hour  or  two.  If  the  pulse-rate  does  not  diminish,  the  reason  should  be 
investigated.  In  every  instance  due  heed  must  be  given  to  the  patient's 
appearance  and  general  condition.  After  certain  thyroidectomies  there 
will  be  a  sudden  rise  of  pulse  to  160  or  180.  Recently  I  observed  after  a 
thyroidectomy  a  patient  whose  pulse  could  not  be  counted  for  several 
hours  on  account  of  its  rapidity.  The  general  condition  was  reassuring, 
however,  and  after  six  hours  of  such  rapid  action  it  gradually  fell  within 
bounds. 

On  the  whole,  the  following  is  an  excellent  guide:  A  pulse  of  120  re- 
quires watching;  a  pulse  of  140  requires  anxious  watching;  a  pulse  of  160, 
if  not  reduced  in  six  hours,  foretells  impending  death. 

During  the  first  hour  after  the  return  of  the  patient  to  bed  the  pulse 
should  be  taken  and  recorded  every  ten  minutes;  during  the  second  hour 
every  fifteen  minutes  provided  consciousness  has  returned;  every  fifteen 
minutes  for  the  third  hour;  half -hourly  thereafter  for  the  next  six  hours; 
and  hourly  during  the  remainder  of  the  first  twenty-four  hours.  If  con- 
ditions are  unsatisfactory  the  nurse  must  make  frequent  examination  of 


I06  SURGICAL   NURSING 

the  pulse  and  note  its  character  and  quahty  and  duly  record  them.  Very 
often  such  frequent  taking  of  the  pulse  will  awaken  suspicion  and  alarm 
in  your  patient's  mind,  and  he  promptly  concludes  his  heart  is  not  strong 
or  that  he  is  in  a  serious  condition.  It  is  always  well  to  inform  the  patient 
that  this  frequent  taking  of  the  pulse  is  a  routine  practice.  By  so  doing 
you  will  forestall  unnecessary  alarm  or  worry  on  the  part  of  the  patient. 

Study  and  years  of  close  observation  will  find  you  more  capable  of 
interpreting  the  heart  and  its  action  as  evidenced  by  the  character,  volume, 
rhythm,  and  rapidity  of  the  radial  pulse. 

The  Chart. — Your  nursing  record  for  the  first  day  should  contain  the 
following  information  for  the  surgeon: 

Pulse. — Record  of  its  rapidity,  character,  volume. 

Respiration. — Hourly  record  of  its  frequency  and  character. 

Temperature. — Its  height  at  3,  6,  9  p.m.  and  12  midnight,  if  awake. 

Chill. — If  a  chill  occurs  the  temperature  is  to  be  taken  at  once  and  half-hourly  thereafter  until 
the  temperature  reaches  its  maximum  and  begins  to  fall. 

Medication. — A  full  record  of  all  medicines  given  and  the  time  administered.  (If  morphin  is 
administered  have  the  surgeon  initial  each  record  of  it  as  required  by  the  Harrison  law.  This  holds 
true  of  all  opium  or  cocain  preparations.) 

Rest. — Record  the  amount  of  time  the  patient  slept. 

Urination. — Record  the  number  of  ounces  voided  and  whether  it  was  voluntary  or  by  catheter. 

Water  and  Nourishment. — Chart  the  amount  consumed  and  note  whether  nausea  was  present 
and  if  vomiting  occurred. 

Comments. — Note  the  patient's  general  condition  and  actions. 

Details  of  Operation. — Surgeon,  his  assistants,  names  of  all  principals  engaged  in  the  operation, 
and  of  witnesses.  What  anesthetic  was  given,  when  started,  and  when  mthdrawn.  When  the 
operation  was  begun  and  time  completed.  What  was  done.  Note  disposition  of  pathological  speci- 
mens and  tissues  removed  during  operation.     Condition  of  patient  when  returned  to  bed. 

Make  the  chart  more  than  a  record  of  a  few  figures  and  meaningless 
comments.  Make  it  demonstrate  that  you  have  been  alert  to  everything 
that  has  transpired,  and  let  it  convey  to  the  surgeon  a  complete  report  of 
his  patient's  condition  and  progress  during  every  moment  of  his  absence. 

Friends  and  Relatives. — The  patient's  family  and  friends  usually  are 
intensely  interested  in  the  condition  and  progress  and  will  be  desirous 
of  going  into  the  sickroom  frequently  to  allay  their  fears.  It  is  here  that 
a  nurse  will  be  called  upon  to  exercise  considerable  tact  and  judgment. 
Quietly  but  firmly  impress  them  with  the  fact  that  the  patient's  recovery 
is  partly  dependent  upon  his  being  kept  quiet  and  undisturbed.  The 
most  intimate  relatives  may  be  admitted  to  the  room  after  the  patient  is 


POST-OPERATIVE  NURSING  DURING  THE  FIRST  TWENTY-FOUR  HOURS     IO7 

in  bed,  and  then  requested  to  retire  when  the  early  signs  of  returning 
consciousness  are  manifested.  When  the  patient  is  fully  conscious  they 
may  be  admitted  again  for  a  moment  to  speak  a  few  words  of  encourage- 
ment. None  but  the  immediate  family  should  be  admitted ;  friends  should 
be  denied  entrance  until  convalescence  is  well  established.  No  rule  as  to 
visitors  can  be  laid  down;  circumstances  must  guide  the  nurse  in  deter- 
mining when  they  may  be  permitted  to  see  the  patient. 

The  foregoing  is  based  upon  the  normal  progress  of  a  patient  during  the 
first  twenty-four  hours  succeeding  an  operation  and  the  duty  of  the 
attending  nurse  during  that  period.  It  is  not  presumed  that  every  opera- 
tive patient  experiences  such  smooth  progress.  Emergencies  frequently 
arise  and  serious  complications  often  present  themselves  so  that  more 
active  attendance  on  the  part  of  the  nurse  is  demanded.  They  are  of 
such  vast  importance  that  every  nurse  should  be  intimately  aware  of  their 
nature  and  possibility  as  well  as  of  their  treatment.  We  shall  devote 
another  chapter  to  their  discussion.  Before  doing  so,  we  shall  consider 
the  patient's  progress  along  the  normal  course  during  the  succeeding  days 
of  convalescence. 


CHAPTER  VIII 

POST-OPERATIVE  CARE  IN  NORMAL  CONVALESCENCE  AFTER  THE  FIRST 

TWENTY-FOUR  HOURS 

The  night  following  the  operation  may  be  one  of  almost  ceaseless 
activity  and  anxious  watching,  or  it  may  be  a  period  of  rest  from  which 
the  patient  awakes  with  the  mind  clear  and  with  yesterday's  experiences  a 
hazy  and  indistinct  memor}^  In  normal  cases  the  night  will  have  been 
one  of  comparative  rest  provided  morphin  has  been  judiciously  used,  and 
the  patient  will  be  found  wdth  the  temperature  normal  and  a  pulse  of 
from  80  to  100. 

The  first  duty  that  awaits  the  nurse  on  the  morning  of  the  first  post- 
operative day  is  the  toilet  of  the  patient.  The  hands  and  face  should  be 
bathed,  the  mouth  and  teeth  cleansed,  and  the  pillows  and  bedclothes 
arranged.  Unless  contraindicated,  some  form  of  liquid  nourishment 
must  be  prepared  for  the  patient.  This  task  accomplished,  the  nurse 
may  permit  the  patient  to  remain  in  charge  of  an  assistant  while  she  goes 
to  breakfast. 

The  day  will  be  a  busy  one.  The  cleansing  or  sponge  bath  is  first  in 
order  and  an  alcohol  rub  following  it  will  be  beneficial  to  the  patient.  The 
bath  and  rub  completed,  the  abdominal  binder,  if  a  laparotomy,  should 
be  readjusted.  This  affords  an  opportunity  for  the  nurse  to  ascertain 
whether  the  dressings  are  maintained  in  place  and  remain  unsoiled.  The 
bed  should  then  receive  attention  and  clean  linen  replace  that  which  is 
soiled.  After  the  room  is  put  in  order  the  morning's  general  care  will  be 
finished. 

The  nurse  should  now  direct  her  attention  to  making  the  morning 
entries  on  her  chart  and  then  await  the  surgeon's  visit.  Normal  progress 
occurring,  the  surgeon  probably  will  leave  orders  somewhat  similar  to  the 

following : 

108 


POST-OPERATIVE    CARE    IN   NORMAL   CONVALESCENCE  IO9 

Water  freely;  liquid  nourishment,  q.  2  or  3  h. 

Strychnin,  gr.  J40,  by  mouth,  q.  4  h. 

If  flatus  of  an  annoying  degree  occurs  insert  rectal  tube  or  give  a  low  enema. 

Morphin,  gr.  J-g,  or  codein,  gr.  i,  p.  r.  n.  for  restlessness  or  pain. 

T.  P.  R.,  q.  2h. 

Besides  carrying  out  these  orders  the  nurse's  duty  will  consist  in 
ministering  to  her  patient  in  such  manner  as  will  secure  the  greatest 
amount  of  comfort  and  rest. 

After  the  noon  nap  the  patient  will  experience  ''muscle  ache,"  languor 
from  the  normal  surgical  rise  of  temperature  of  one  to  two  degrees,  and, 
possibly,  distention  from  an  accumulation  of  intestinal  flatus  or  from 
operative  trauma. 

In  order  to  secure  a  comfortable  position  the  patient  will  move  about, 
thereby  producing  sharp  twinges  of  pain  in  the  wound.  This  pain  may 
cause  fretfulness  and  restlessness,  which  may  be  prevented  or  lessened 
by  one  or  more  of  the  following  expedients  with  which  the  efficient  nurse 
should  be  familiar: 

Changing  the  pillows. 
Placing  a  pillow  under  the  knees. 

Gently  turning,  the  patient  on  her  side  and  supporting  her  in  that  position  with  pillows  at  her 
back,  and  at  the  same  time  placing  a  pillow  between  her  knees. 
Alcohol  rubs. 
Bathing  hands  and  face. 
Cold  compresses  on  the  forehead. 
Suitable  and  appealing  liquid  nourishment. 
Brief  periods  of  diverting  conversation. 
Frequent  airing  of  the  sick  chamber. 

The  nourishment  found  most  suitable  and  acceptable  in  liquid  form 
consists  of: 

Albumin  water  flavored  with  orange  or  lemon  juice. 

Beef  extract  or  strained  broths. 

Milk  with  limewater. 

Tea,  cocoa,  or  grape  juice  diluted  with  plain  water  or  carbonated  water. 

While  liquid  nourishment  may  be  ordered  every  two  hours,  it  would 
not  be  a  wise  policy  to  insist  on  its  ingestion.  Water  is  to  be  given  freely. 
Care  must  be  exercised  to  prevent  vomiting  by  overloading  the  stomach 
which  may  still  be  somewhat  irritable  from  the  after-effects  of  the  anes- 
thetic.    One  need  not  worry  because  the  patient  expresses  an  antipathy 


no  SURGICAL   NURSING 

to  nourishment  during  the  second  day.  The  chief  concern  should  be  to 
induce  the  consumption  of  fairly  large  quantities  of  water. 

Even  after  the  nurse  has  done  everything  that  can  be  done,  four  o'clock 
may  find  the  patient  fretting  and  complaining.  In  this  event  one  grain  of 
codein  is  indicated.  A  tranquil  state  will  follow-  and  the  patient  will  soon 
fall  asleep.     Awakening,  she  will  be  remarkably  refreshed  and  quieted. 

At  seven  o'clock  the  nurse  should  commence  preparing  the  patient  for 
the  night.  This  preparation  includes  an  alcohol  rub,  bathing  the  hands 
and  face,  and  cleansing  the  mouth.  The  bedclothes  and  pillows  are  to  be 
neatly  arranged  for  the  patient's  comfort  and  to  induce  sleep.  These 
preparations  completed,  the  windows  should  be  raised  to  secure  proper 
ventilation,  the  lights  lowered,  and  quiet  throughout  the  house  insisted 
upon. 

Normally,  the  patient  should  soon  fall  into  a  quiet  slumber.  If,  after 
an  hour  or  two,  the  nurse  finds  her  still  awake  and  signs  of  renewed  restless- 
ness appearing,  another  grain  of  codein  may  be  administered.  Following 
this  there  should  occur  five  to  seven  hours  of  slumber,  interrupted  only  by 
a  request  for  a  drink,  a  change  of  posture,  or  the  rearrangement  of  pillows. 
The  morning  of  the  third  day  will  find  the  normal  patient  refreshed  and 
with  signs  of  early  convalescence  apparent. 

FLATUS 

Flatus  is  occasioned  chiefly  by  the  entrance  of  air  into  the  abdominal 
cavity  through  the  operative  wound,  by  prolonged  exposure  and  handling 
of  the  intestines  during  the  operation,  by  the  operative  work  upon  the 
intestines  themselves,  drastic  preoperative  catharsis,  and  the  use  of  too 
much  morphin  which  arrests  peristalsis  with  consequent  failure  to  empty 
completely  the  gastrointestinal  tract. 

Flatus  first  evidences  itself  from  twelve  to  twenty-four  hours  after  the 
operation.  It  is  characterized  by  abdominal  distention  and  colicky  pain 
(gripes),  both  of  which  increase  pain  in  the  wound  by  reason  of  the  wound 
tension.  The  patient  complains  of  feeling  "full,"  and  that  the  binder  is 
tight. 

The  condition  is  very  annoying,  and  the  frequent  griping  attacks  oc- 


POST-OPERATIVE   CARE   IN  NORMAL   CONVALESCENCE  III 

casion  marked  discomfort  and  restlessness.  It  is  difficult  to  describe  the 
discomforts  resulting  from  flatus.  One  must  personally  experience  its 
distress  before  becoming  fully  appreciative  of  the  importance  of  instituting 
measures  calculated  to  afford  relief. 

When  these  gas  pains  occur,  the  nurse,  unless  receiving  distinct  orders 
to  the  contrary  or  the  nature  of  the  operation  itself  contraindicates,  should 
institute  the  following  procedures: 

The  insertion  of  a  rectal  tube  for  a  distance  of  four  to  six  inches.  If  this  is  effective  it  may  be 
repeated  as  frequently  as  required. 

A  low  salt  and  glycerin  enema.  The  flatus  will  often  be  expelled  in  fifteen  to  thirty  minutes  after 
the  expulsion  of  the  enema. 

The  injection  into  the  rectum,  under  low  pressure,  of  six  to  eight  ounces  of  milk  of  asafetida. 
Repeat  as  indicated. 

A  low  oil  and  turpentine  enema. 

Frequent  change  of  position. 

Carminative  drinks,  such  as  ginger  or  peppermint. 

Milk  of  magnesia  in  one-dram  doses  or  soda  mint  tablets  by  mouth. 

The  withholding  of  morphin,  which  should  at  all  times  be  employed  as  sparingly  as  possible. 

These  measures  properly  employed  will,  as  a  rule,  bring  rehef .  If  not, 
the  condition  becomes  one  of  great  concern  and  falls  into  the  class  of  post- 
operative emergencies. 

CATHARTICS 

It  is  desirable  to  secure  a  movement  of  the  bowels  usually  by  the  third 
day.  The  method  employed  to  produce  it  will  vary  naturally  with  every 
operation.  In  other  than  abdominal  work,  a  course  of  calomel  followed 
by  magnesium  sulphate,  citrate  of  magnesia,  castor  oil,  or  cathartic  pills 
may  be  employed,  according  to  the  surgeon's  custom.  In  abdominal  cases 
the  result  desired  is  generally  induced  by  means  of  enemata  administered 
on  the  morning  of  the  third  day.  The  enemata  consist  commonly  of 
ordinary  soapsuds,  oil,  salt,  and  glycerin,  or  at  times  of  the  old  enema,  oil, 
soapsuds,  turpentine,  and  water.  The  enemata  should  be  repeated  for 
one  or  two  days,  after  which  they  are  discontinued.  If  a  cathartic  is  still 
required,  it  is  customary  to  order  pulvis  glycyrrhizse  compositus  (com- 
pound licorice  powder),  cascara,  citrate  of  magnesia,  a  cathartic  pill,  or  a 
saline  laxative  as  frequently  as  necessary  to  secure  one  or  two  free  bowel 
movements  dailv. 


112  SURGICAL   NURSING 

CATHETERIZATION 

How  soon  after  an  operation  should  a  patient  be  urged  to  void  urine, 
and  when  failing  to  do  so  when  should  she  be  catheterized?  We  must 
remeraber  that  just  previous  to  being  placed  on  the  operating  table  the 
patient  was  catheterized  and  the  bladder  entirely  emptied,  that  the  first 
post-operative  hours  were  devoid  of  the  ingestion  of  water,  and  that  the 
patient  undoubtedly  perspired  more  or  less  freely.  Consequently,  the 
kidney  secretion  will  be  diminished  during  the  first  twenty-four  hours. 


Fig.  78. — Tray  for  Catheterization. 

Catheters,  cotton  balls,  and  olive  oil  sterilized.     The  nurse  with  sterile  gloved  hand  removing 

catheter  from  basin  in  which  it  was  boiled. 

As  a  rule,  if  no  discomfort  is  expressed,  eight  to  ten  hours  may  be 
permitted  to  elapse  before  suggesting  to  the  patient  the  desirability  of 
urination.  If  unable  to  void  urine  voluntarily  and  there  is  no  complaint 
of  distress  the  patient  may  be  permitted  to  go  one  or  two  hours  longer 
before  the  second  attempt  is  urged.  If  the  patient  is  still  unable  to  urinate, 
the  application  of  hot  towels  to  the  vulva  or  the  pouring  of  warm  water 
over  the  vulva  will  frequently  induce  voluntary  urination.  If  unsuccess- 
ful, it  then  becomes  necessary  to  catheterize.  The  only  exception  is  in 
patients  Avho  have  undergone  hysterectomy,  plastic  repair  of  the  vault 
of  the  vagina,  or  work  upon  the  bladder.  In  these  cases  distention  of  the 
bladder  must  be  prevented  either  by  voluntary  evacuation  of  urine  or  by 
catheterization  every  six  or  eight  hours. 


POST-OPERATIVE    CARE    IN   NORMAL    CONVALESCENCE 


i^3 


Some  patients  cannot  pass  urine  voluntarily  while  lying  in  bed.  Here 
catheterization  will  have  to  be  done  every  eight  or  ten  hours. 

Every  precaution  should  be  observed  to  make  catheterization  a  sterile 
procedure  (Fig.  78).  //  must  always  he  performed  under  direct  inspection. 
When  repeated  catheterization  becomes  necessary,  some  surgeons  will 
direct  that  a  dram  or  two  of  a  5  or  10  per  cent,  solution  of  argyrol  be 
injected  into  the  bladder  just  preceding  the  withdrawal  of  the  catheter  and 
permitted  to  remain.  Others  may  order  urotropin  in  powder  or  in  liquid 
suspension  to  be  given  by  mouth  three  or  four  times  a  day  as  a  urin- 
ary antiseptic.  This  precaution  is  observed  to  prevent  so  far  as  possible 
occurrence  of  cystitis,  which  is  a  frequent  consequence  of  repeated 
catheterization. 


Fig.  79. — Preparing  for  an  Abdominal  Dressing. 
Bedclothes  and  nightgown  turned  back  and  covered  with  sterile  towels.     Scultetus  binder  in  situ. 

DRESSINGS 

When  the  general  condition  of  the  patient  indicates  a  normal  convales- 
cence— normal  temperature  and  absence  of  complaint  that  might  indicate 


114 


SURGICAL   NURSING 


infection  or  wound  disturbance — it  is  rarely  necessary  to  inspect  or  dress 
the  wound  until  after  the  lapse  of  a  week  or  ten  days.  The  only  attention 
directed  to  the  dressings  is  to  ascertain  that  they  are  in  place  and  to  read- 
just the  external  binder. 

At  the  end  of  a  week  or  ten  days  the  surgeon  will  inspect  the  wound  and 


Fig.  8o. — The  Nurse  Untying  Abdominal  Tapes. 
Scultetus  bandage  removed,  entire  field  draped  witli  sterile  towels,  required  supplies  at  hand: 
bottles  of  alcohol  and  iodin,  basin  for  alcohol,  sterile  gauze,  paper  bag  for  soiled  sponges  and  dress- 
ings removed,  and  sterile  instruments  (from  right  to  left,  grooved  director,  two  pairs  scissors,  two 
artery  snaps,  suture  forceps). 


remove  whatever  tension  sutures  may  have  been  inserted. 
is  one  that  should  be  characterized  by  a  sterile  technique. 
For  dressing  the  wound  the  following  will  be  required : 


This  process 


Sterile  towels. 
Pair  of  gloves. 
Scissors. 
Tissue  forceps. 


Probe. 

Sterile  dressing  gauze. 

Alcohol. 

Adhesive  plaster. 


While  the  surgeon  is  washing  his  hands  the  nurse  should  direct  her 
attention  to  arranging  the  patient  and  draping  the  field.  The  nightdress 
should  be  folded  up  on  the  chest  and  the  bedclothes  turned  down  to  the 


POST-OPERATIVE    CARE    IN   NORMAL    CONVALESCENCE 


II 


pubes  and  covered  with  sterile  towels  well  tucked  under  above  and  below 
the  wound  (Fig.  79) .  Instruct  the  patient  to  keep  her  hands  above  her 
head  so  as  not  to  interfere  with  the  drapings.  It  is  always  well  to  assure 
the  patient  that  she  need  not  be  alarmed,  as  the  procedure  will  be  attended 
by  very  little  if  any  discomfort. 

The  field  is  then  draped  with  other  sterile  towels.     The  instruments, 


Fig.  81  — Placing  Abdominal  Pad  in  a  Paper  Bag. 
Nurse  has  untied  the  adhesive  tapes  and  is  placing  the  abdominal  pad  in  the  paper  bag.     Other 
dressings  covering  wound  in  situ  and  maintained  with  adhesive  strips  that  were  applied  at  the  com- 
pletion of  the  operation. 


which  have  been  sterilized,  are  placed  on  one  of  the  sterile  towels,  as  are 
also  the  opened  packages  of  gauze  (Fig.  80).  The  external  binder  is 
opened,  the  adhesive  tape  strings  untied,  and  the  abdominal  pad  and 
superficial  dressings  lifted  from  place  (Fig.  81).  The  surgeon  or  nurse 
will  remove  the  dressings  which  are  in  direct  contact  with  the  wound 
(Fig.  82). 

After  the  stitches  are  removed  (Fig.  83),  the  wound  may  be  bathed 
with  a  moist  alcohol  sponge,  after  which  it  is  again  covered  with  sterile 


ii6 


SURGICAL   NURSING 


gauze  held  in  place  with  one  or  two  strips  of  adhesive  plaster.  The 
adjustment  of  the  abdominal  pad  and  binder  completes  the  procedure. 
Wounds  in  which  drainage  is  employed  or  which  have  become  infected 
and  require  daily  dressing  must,  of  course,  be  frequently  exposed,  and 
when  so  exposed  they  should  be  draped  in  the  manner  described.  The 
methods  employed  in  these  instances  will  be  described  in  another  chapter, 


Fig.  82. — Removing  the  Last  Dressings. 
Abdominal  pad  has  been  put  in  the  paper  bag  supplied  to  receive  soiled  dressings.     Nurse  has 
loosened  the  adhesive  straps  holding  these  dressings  in  place  without  contaminating  the  field.     With 
removal  of  these  last  dressings  the  field  is  ready  for  the  surgeon  to  remove  the  sutures. 


"The  Process  of  Healing  and  Care  of  Wounds."  Every  time  a  wound  is 
inspected  or  treated  a  record  should  be  made  on  the  daily  chart.  The 
time  that  the  stitches  are  removed  should  be  noted,  as  well  as  the  name  of 
the  person  who  assumed  that  responsibility. 

As  a  rule,  at  the  end  of  two  weeks  all  dressings  may  be  entirely  removed 
from  a  wound  that  has  healed  by  primary  intention.  Union  will  then  have 
been  firmly  produced  and  further  dressings  will  not  be  required.     Band- 


POST-OPERATIVE    CARE    IN   NORMAL    CONVALESCENCE 


117 


ages,    abdominal    supports,    and   similar   contrivances   are    but    seldom 
required.     The  corset  may  be  worn  as  soon  as  the  patient  wishes. 


GETTING  UP 


No  definite  time  can  be  set  as  to  when  the  patient  may  first  sit  up  or 
get  out  of  bed.     This  can  be  determined  only  by  the  surgeon  after  con- 


FiG.  83. — Removal  of  Sutures  by  Surgeon. 
Surgeon    wearing   sterile   gloves    and    holding    suture    cutting    scissors    and    suture    forceps. 
Note. — In  order  to  photograph  the  removal  of  sutures  it  was  necessary  for  the  surgeon  to  stand  in 
the  nurse's  place. 

sidering  the  nature  of  the  operation  that  has  been  performed,  the  course 
of  convalescence,  and  the  patient's  general  physical  condition.  The 
former  practice  of  two  to  three  weeks'  rest  in  bed  is  now  generally  aban- 
doned, and  the  tendency  is  to  permit  the  patient  to  leave  the  bed  early. 
This  practice,  it  has  been  found,  has  a  tendency  toinduce  an  early  and 
speedy  return  to  normal  strength. 

When  the  surgeon  has  given  his  permission  to  the  patient  to  sit  up,  it 


Il8  SURGICAL   NURSING 

is  incumbent  upon  the  nurse  to  see  that  these  orders  are  carried  out  with 
reason.  To  permit  a  patient  to  sit  up  with  a  back  rest  for  the  first  time 
for  a  period  of  an  hour  or  longer  is  unreasonable.  Patients  sitting  up  for 
the  fir'st  time  should  not  be  granted  the  privilege  longer  than  fifteen  min- 
utes. A  return  to  the  recumbent  position  should  then  be  insisted  upon. 
Gradually  the  time  may  be  lengthened,  but  between  the  periods  there 
should  be  a  reasonable  time  for  rest.  The  same  precaution  should  be 
observed  when  the  patient  gets  out  of  bed  to  sit  in  a  chair.  It  will  be  well 
to  inform  the  patient  that  there  may  be  a  feeling  of  dizziness,  prickling  of 
the  limbs,  or  even  a  fainting  spell  when  she  first  attempts  to  sit  up.  The 
patient  will  then  not  be  alarmed  should  such  an  unpleasant  experience 
occur.  These  occurrences  may  be  prevented  to  a  great  extent  if  the 
patient  be  gradually  placed  in  an  upright  position. 

When  the  patient  sits  up  there  may  be  noted  at  times  a  rather  marked 
increase  in  pulse-rate  and  even  a  slight  rise  in  temperature.  These  con- 
ditions need  occasion  no  alarm,  as  a  return  to  normal  will  speedily  follow. 
If  a  persistent,  rapid,  and  small  pulse  is  met  with,  the  patient  should  be 
returned  to  bed  and  the  periods  of  sitting  up  shortened  until  the  accelera- 
tion of  the  pulse  becomes  less  marked. 

On  the  day  following  the  first  attempt  to  sit  up  the  patient  may 
complain  of  muscle  stiffness  or  soreness.  It  is  the  result  of  yesterday's 
change  in  position,  and  the  muscle  work  required  in  maintaining  it.  The 
soreness  will  disappear  after  a  few  days,  when  the  muscles  regain  their 
former  tone  and  strength.  In  some  patients  the  discomfort  does  not 
disappear  for  several  days  or  even  weeks.  General  massage  of  the  back 
and  limbs  will  be  found  most  useful  in  relieving  these  aches  and  muscle 
pains. 

The  succeeding  days  witness  the  patient's  return  to  that  stage  of  con- 
valescence when  the  services  of  the  nurse  are  no  longer  required.  When 
leaving  the  case  offer  your  chart  to  the  surgeon  for  filing  with  his  records. 
If  he  does  not  desire  to  keep  it,  it  is  advisable  that  it  be  destroyed  before 
you  leave  the  patient's  home. 

We  feel  certain  that  every  nurse  who  faithfully  and  cheerfully  perforrns 
the  duties  required  by  her  patient  will  receive  the  good  wishes  of  the 


POST -OPERATIVE    CARE    IN   NORMAL    CONVALESCENCE  IIQ 

patient  and  family  whom  she  loyally  serves,  and  there  will  be  expressions 
of  regret  over  the  severing  of  the  relationship  of  patient  and  nurse. 
These  are  the  nurse's  reward  over  and  above  the  monetary  return  received, 
and  are  the  permanent  records  which  characterize  her  in  her  community 
as  a  desired,  dependable,  and  faithful  nurse. 


CHAPTER  IX 
POST-OPERATIVE  EMERGENCIES 

A  surgical  emergency  is  the  alarm  signal  that  calls  forth  the  greatest 
reserve  training  and  ability  of  the  attending  nurse.  The  efficiency  with 
which  the  nurse  meets  the  responsibility  thus  suddenly  thrust  upon  her 
frequently  determines  the  ultimate  outcome  of  the  operative  procedure. 
The  promptness  with  which  the  nurse  detects  the  onset  of  an  emergency 
and  the  efforts  she  institutes  to  forestall  or  combat  its  progress  are  de- 
pendent upon  her  knowledge  of  the  nature,  symptomatology,  and  treat- 
ment of  post-operative  emergent  complications.  No  nurse  should  ever 
assume  the  entire  charge  of  a  surgical  patient  unless  she  possess  this 
knowledge. 

The  operation  over,  the  patient  in  bed,  and  the  surgeons  gone,  the 
progress  of  the  patient  should  and  must  always  be  the  nurse's  sole  and 
primary  concern.  The  lapse  of  one  or  several  hours  after  the  completion 
of  any  operation  is  the  first  period  wherein  certain  emergencies  may  occur. 
The  second  period  is  the  first  two  or  three  post-operative  days.  The  third 
period  is  from  the  sixth  to  the  tenth  or  the  twelfth  post-operative  day. 
While  emergencies  are  possible  at  any  period,  any  hour,  or  any  moment, 
experience  has  taught  that  certain  definite  forms  of  complications  occur 
in  three  designated  portions  of  the  convalescent  period.  Tabulated, 
these  emergencies  are: 


First  Period 

9- 

Exhaustion. 

I. 

Respiratory  collapse. 

lO. 

Toxic  singultus  (hiccup) 

2. 

Circulatory  collapse. 

II. 

Hyperpyrexia. 

3- 

Shock. 

12. 

Persistent  vomiting. 

4- 

Hemorrhage. 

Third  Period 

Second  Period 

I. 

Sepsis,  or  septicemia. 

I. 

Cardiac  exhaustion. 

2. 

Pneumonia. 

2. 

Delayed  hemorrhage. 

3- 

Phlebitis. 

3- 

Intestinal  obstruction. 

4- 

Anuria:  uremia. 

4- 

Ileus. 

5- 

Obstruction. 

5- 

Acute  gastric  dilatation. 

6. 

Cardiac  exhaustion. 

6. 

Acute  anuria:  uremia. 

7- 

Secondary  hemorrhage. 

7- 

Peritonitis. 

8. 

Peritonitis. 

8. 

Pneumonia. 

POST-OPERATIVE    EMERGENCIES  121 

The  patient  may  apparently  be  in  good  condition,  when  suddenly  a 
change  is  noticed.  Her  expression,  pulse,  respiration,  and  actions  show 
that  progress  is  no  longer  satisfactory,  and  that  an  emergency  presents 
itself  which  demands  prompt  and  possibly  heroic  procedure.  The  famih- 
and  friends  are  prone  to  recognize  the  critical  conditions,  and,  in  their 
overanxiety,  frequently  add  to  the  complexity  of  the  situation  by  their 
thoughtless  and  hysterical  attempts  to  render  aid. 

The  nurse  who  meets  such  an  emergency  in  a  calm,  master-of-the- 
situation  manner,  and  institutes  a  definite  plan  of  action  until  the  doctor 
or  surgeon  arrives,  is  entitled  to  our  sincerest  respect  and  admiration. 
Upon  her  judgment  and  discretion  much  depends. 

To  enable  the  nurse  to  acquit  herself  in  a  commendable  manner,  as 
well  as  to  render  the  most  efficient  aid  to  her  patient,  it  will  be  my  purpose 
to  outline  the  salient  diagnostic  points  of  the  more  common  emergencies 
and  the  treatment  that  is  within  the  province  of  the  nurse  to  administer. 
Such  activities  call  for  immediate  communication  with  the  surgeon  or 
attending  physician,  and  the  institution  of  the  recognized  treatment. 

In  sending  for  the  surgeon  or  physician,  so  explain  the  nature  of  the 
emergency  that  your  messenger  will  be  able  to  repeat  it  to  the  surgeon  when 
he  is  reached  by  telephone  or  personal  summons.  By  sending  such  an 
informative  call,  the  doctor  will  be  able  to  bring  with  him,  without  loss  of 
time,  such  remedies  and  supplies  as  are  necessary  for  treatment.  Nothing 
is  so  exasperating  as  to  receive  a  call  in  a  high-strung,  hysterical  voice: 

"Come  at  once.  Doctor.     Mrs. is  dying."     Though  the  doctor  thus 

summoned  takes  with  him  certain  supplies,  his  arrival  at  the  bedside 
usually  finds  him  without  the  articles  which  he  requires  but  which  he  could 
readily  have  brought  with  him  had  he  received  an  intelligent  report. 
Valuable  time  is  thus  consumed  and  the  patient's  danger  increased  by  the 
delay. 

SHOCK  AND  HEMORRHAGE 

Shock  is  defined  as  a  lowering  of  the  vital  powers  whereby  there  is 
produced  a  complete  or  transitory  cardiac  embarrassment  with  spasm  of 
the  extreme  vessels  and  a  depression  of  nerve  function.     It  may  be  of  any 


122  SURGICAL   NURSING 

grade  of  severity  from  a  transitory  derangement  of  circulatory  function 
to  profound  collapse  and  speedy  death.  The  exact  pathology  of  shock  is 
at  present  unknown,  as  post-mortem  examinations  do  not  reveal  the 
etiological  factors.  Much  study  and  discussion  have  resulted,  and  numer- 
ous, as  well  as  varied,  opinions  are  held  by  different  members  of  the  pro- 
fession, but  gradually,  as  more  accurate  information  comes  into  our  pos- 
session, many  of  the  former  conclusions  are  discarded  because  they  are  no 
longer  tenable. 

It  is  generally  conceded  that  shock  attends  or  results  from  the  loss  of 
large  amounts  of  blood,  rough  or  unskilled  handhng,  exposure  of  vital 
tissues  or  organs,  prolonged  operative  work,  or  the  oversaturation  with  the 
anesthetic.  It  is  my  experience  and  opinion  that  the  phenomena  of  shock 
result  chiefly  from  the  loss  of  large  amounts  of  blood;  in  other  words,  that 
shock  is  but  an  after-result  of  operative  hemorrhage  and  that  when  the 
loss  of  blood  during  operation  is  minimized,  shock  does  not  result.  The 
phenomena  of  shock  may  be  interpreted  as  the  result  of  hemorrhage  or  the 
loss  of  a  devitalizing  quantity  of  blood.  This  is  the  most  frequent  cause, 
and  it  will  be  noted  that  the  degree  of  shock  is  in  direct  ratio  to  the  amount 
of  blood  lost  during  or  after  the  operation.  I  do  not  recall  the  presence  of 
shock  in  or  after  any  operative  procedure  where  a  conservative  hemostasis 
had  been  accomplished. 

Shock  has  evidenced  itself  in  ectopic  pregnancy  with  hemorrhage  into 
the  free  abdominal  cavity,  in  operations  upon  the  brain  where  inadver- 
tently large  amounts  of  blood  had  escaped  from  the  scalp  and  dural 
vessels,  in  placenta  praevia,  and  in  nephrectomy  when  the  kidney  vessels 
had  slipped  from  the  hemostats  and  a  great  deal  of  blood  lost  before  they 
were  again  secured.  In  consultation,  I  have  seen  shock  in  cases  where 
delayed  or  secondary  hemorrhage  had  occurred  from  the  slipping  of  liga- 
tures from  the  pedicles  containing  large  vessels.  In  view  of  this  experi- 
ence, I  have  become  accustomed  to  look  for  the  source  of  shock  in  the 
amount  of  hemorrhage  that  has  occurred  or  is  occurring.  If  shock  symp- 
toms do  not  appear  until  twelve  or  twenty-four  hours  after  the  patient  has 
returned  to  bed,  the  conclusion  may  be  made  that  delayed  hemorrhage  is 
taking  place  and  its  source  must  be  detected  and  arrested. 


POST-OPERATIVE   EMERGENCIES  1 23 

Symptoms. — The  symptoms  that  denote  the  presence  of  shock  and 
enable  us  to  recognize  the  condition  are : 

A  pulse  of  120  to  160,  small,  running,  and  of  small  caliber. 

Pale,  clammy,  cold  skin,  hands,  and  feet. 

Increased  and  shallow  respirations. 

A  temperature  of  98.6°  or  as  low  as  97°. 

Mental  alertness,  excitability,  or  delirium. 

Semiconsciousness  or  complete  unconsciousness. 

Restlessness. 

If  a  gradual  loss  of  blood  is  occurring,  the  patient  will  express  her  feel- 
ings thus:  "I  feel  so  queer,"  "My  head  feels  light,"  "The  room  is  dark," 
"My  ears  ring,"  or  similar  expressions  denoting  the  presence  of  cerebral 
anemia. 

The  mucous  membranes,  lips,  ears,  and  finger  nails  will  indicate  the 
absence  of  blood  and  lose  their  normal  color. 

Vomiting  may  occur. 

These  symptoms  will  exist  in  varying  degree,  depending  upon  the 
severity  and  gravity  of  the  condition.  The  diagnosis  is  based  upon  the 
rate  and  character  of  the  pulse,  the  temperature,  and  the  patient's  general 
appearance. 

While  we  may  encounter  a  post-operative  condition  in  which  there  is  a 
rapid  pulse  that  ranges  from  120  to  160  for  from  one  to  several  hours,  and 
during  which  the  patient  is  listless  or  only  semiconscious,  with  a  pale  skin, 
the  condition  cannot  rightly  be  termed  shock.  It  is  a  condition  of  cardiac 
fatigue  or  depression  arising  from  the  prolonged  exposure  or  handling  of 
vital  organs  or  tissues  and  deranged  enervation.  The  complex  symptoms 
of  shock  are  absent. 

The  condition  referred  to  in  the  preceding  paragraph  is  more  properly 
the  result  of  nerve  trauma  and  is  understandable  when  we  are  familiar 
with  Crile's  theory  of  anoci-association.  The  condition  does  not  ensue 
when  Crile's  methods  of  prevention  are  employed.  It  is  a  preventable 
complication. 

Prevention. — Preventive  measures  include  careful  hemostasis  and 
careful  ligation  of  possible  bleeding  points,  expeditious  operating,  and  a 
minimum  of  trauma. 


124  SURGICAL   NURSING 

Treatment. — The  treatment  of  shock  consists  of  the  following  meas- 
ures : 

Control  of  bleeding  vessels  by  packing,  artery  forceps,  or  by  reopening  the  wound  and  religating 
the  vessels. 

Replacing  the  loss  of  blood  with  salines  (intravenous,  subcutaneous,  or  rectal)  and  transfusion  of 
blood. 

Morphin,  grain  3'^  to  ^^i  by  hypodermic.  Careful  stimulation  with  camphor  oil  or  whiskey. 
Strychnin  is  of  little  avail,  as  are  the  other  common  heart  stimulants.  Strychnin  is,  however,  a 
valuable  adjuvant  to  patients  suffering  from  nerve  trauma  and  depression. 

Local  heat. 

Elevation  of  the  foot  of  the  bed  if  not  contraindicated  by  reason  of  abdominal  drainage. 

Abundance  of  fresh  air. 

Quiet  surroundings. 

Reconstructing  blood  remedies  and  nourishing  food. 

What  procedure  should  a  nurse  pursue  when  she  finds  her  patient  with 
symptoms  of  shock,  and  medical  assistance  is  not  immediately  available? 
The  following  are  all  within  her  province  and  their  employment  will  be  her 
most  effective  treatment  until  the  surgeon  or  the  physician  arrives. 

1.  Send  for  the  surgeon. 

2.  If  an  active,  open,  visible  hemorrhage  presents  itself,  control  it  by 
packing  the  wound  with  sterile  gauze,  or,  if  the  bleeding  vessel  is  visible, 
clamp  it  with  a  forceps.  Even  if  sterile  gauze  is  not  available,  the  use  of 
as  clean  gauze  or  linen  as  is  securable  is  justified.  The  possibility  of  in- 
fection is  of  minor  concern  in  the  presence  of  this  greater  emergency.  If 
the  hemorrhage  occurs  from  the  uterus  or  vagina,  pack  the  uterine  cav- 
ity and  vagina  with  gauze  or  cotton,  apply  a  vulvar  pad,  and  a  firm 
T-bandage. 

3.  Give  1-6  to  1-^  grain  of  morphin,  depending  on  the  patient's  age. 

4.  Elevate  the  foot  of  the  bed  if  not  contraindicated. 

5.  Apply  local  heat  in  the  form  of  hot- water  bottles  to  the  extremities 
and  around  the  trunk. 

6.  Commence  a  drop  saline  by  rectum  or  give  a  rectal  enema  of  one 
pint  of  normal  saline.  The  nurse  may  give,  if  capable  of  doing  so  and  the 
doctor's  arrival  is  likely  to  be  much  delayed,  600  to  900  cubic  centimeters 
of  normal  saline  subcutaneously,  preferably  under  the  breasts,  before 
beginning  the  "rectal  drop." 

7.  Give  an  ampule  of  camphor  oil  every  hour  for  three  or  four  doses,  or 
a  hypodermic  of  whiskey,  60  minims,  every  fifteen  minutes  for  four  doses, 


POST-OPERATIVE    EMERGENCIES  I  25 

then  every  half  hour.  The  administration  of  circulatory  stimulation  is 
to  be  governed  in  amount  and  frequency  by  the  character  and  quality  of 
the  pulse.     Be  careful  of  overstimulation. 

8.  Abundance  of  fresh  air. 

9.  By  actions  and  expression  restrain  the  patient's  excitability  and 
prevent  the  relatives  from  creating  hysterical  scenes  in  the  sickroom. 
Make  such  preparation  as  your  judgment  leads  you  to  believe  will  be 
required  by  the  doctor. 

10.  When  the  doctor  arrives,  tell  him  briefly  what  has  occurred  and 
the  measures  you  have  instituted.  A  nurse  who  understandingly  employs 
the  methods  suggested  is  justifying  the  responsibility  that  has  been  placed 
upon  her  and  will  receive  the  hearty  commendations  of  an  appreciative 
surgeon. 

When  the  condition  is  one  of  cardiac  fatigue  or  of  nerve-center  irrita- 
tion, the  nurse  should  be  guided  by  the  same  order  of  procedure.  In 
addition,  strychnin,  grain  }^q  to  j-'so,  depending  on  the  patient's  age, 
administered  every  three  hours,  is  indicated.  The  differential  diagnosis 
from  active  hemorrhage  is  made  by  the  absence  of  pallor  of  the  mem- 
branes, ringing  in  the  ears,  light-headedness,  complaint  of  the  darkness 
of  the  room,  sighing,  rapid,  shallow  respirations,  and  absence  of  bleeding 
vessels.  Remember  that  in  the  majority  of  instances  shock  and  hemor- 
rhage are  synonymous. 

RESPIRATORY  FAILURE  OR  COLLAPSE 

This  condition  arises  during  operative  work  or  in  the  period  of  recovery 
from  the  anesthetic.     It  is  caused  by: 

The  anesthetic. 

An  embolus  affecting  the  nerve  centers  of  the  brain  or  lodging  in  a 
pulmonary  vessel. 

Injury  to  the  pneumogastric  nerves. 

Trauma  to,  or  prolonged  exposure  of,  the  diaphragm. 

Spasm  of  the  glottis. 

Obstruction  of  the  air  passage  by  swallowing  the  tongue  or  inspiration 


126  SURGICAL   NURSING 

into  the  air  passages  of  mucus,  blood  clots,  sponges,  or  artificial  teeth;  the 
dropping  of  the  jaw. 

Lung  collapse  from  perforation  of  the  pleura. 

Intrathoracic  hemorrhage,  possible  in  radical  breast  amputations. 

Symptoms. — The  symptoms  of  respiratory  collapse  are: 

Sudden  or  gradual  cessation  of  respiration. 

Strangling,  struggling  for  air. 

Livid  skin  and  membranes. 

Increased  and  very  rapid  respirations  of  superficial  character. 

The  heart  may  continue  to  beat  for  some  time  after  the  respirations 
have  ceased. 

Treatment. — The  following  measures  may  be  employed  in  treating 
this  emergency: 

1.  Remove  or  combat  the  cause. 

2.  Amyl  nitrite  and  oxygen  inhalations. 

3.  Artificial  respiration. 

4.  Tracheotomy,  if  indicated. 

5.  Respiratory  stimulation  by  camphor  and  strychnin. 

6.  Judicious  heart  stimulation. 

CARDIAC  COLLAPSE 

This  condition  may  occur  during  the  operation  or  at  any  time  until 
complete  convalescence  is  established.     It  may  be  caused  by: 

Emboli  reaching  the  heart — air,  clot,  fat,  or  loosened  thrombic 
fragments. 

Prolonged  strains,  nerve  irritation,  or  sudden  exertion. 

The  anesthetic. 

Valvular  or  myocardial  disease. 

Infections  producing  myocarditis  or  endocarditis. 

Symptoms. — The  symptoms  of  cardiac  failure  are : 

Collapse  with  a  sudden  cessation  of  heart  action  or  with  a  rapidly  rising, 
frequent  pulse  that  soon-  becomes  imperceptible. 

Unconsciousness. 

A  mottled,  mild  lividity  or  extreme  pallor. 


POST-OPERATIVE    EMERGENCIES  1 27 

Respiration  continues  frequently  for  several  minutes  after  complete 
cardiac  collapse  has  occurred. 

Treatment. — For  relieving  this  condition,  the  nurse  should  make  use  of 
the  following  treatment: 

1.  Recumbent  position. 

2.  Removing  or  combating  the  cause. 

3.  Camphor  oil,  whiskey,  nitroglycerin,  or  cardiac  stimulation. 

This  complication  often  occurs  so  suddenly  and  the  termination  is  apt 
to  be  so  rapidly  fatal  that  there  is  little  or  but  brief  opportunity  for  the 
treatment  of  the  emergency. 

CARDIAC  EXHAUSTION  OF  THE  SECOND  PERIOD 

As  a  rule,  the  pulse  should  fall  below  loo  within  forty-eight  to  seventy- 
two  hours.  The  existence  of  some  untoward  condition,  such  as  an  infec- 
tion, absorption  pneumonia,  or  a  continued  temperature  of  ioo°  or  higher, 
entailing  an  increased  heart  action  with  a  pulse  ranging  from  no  to  130, 
may  result  in  cardiac  failure. 

Septic  infection  may  be  followed  by  an  infective  myocarditis,  endo- 
carditis, or  pericarditis,  with  eventual  cardiac  failure  as  a  possibility. 

Dislodged  fragments  of,  or  the  entire,  thrombus  may  reach  the  heart 
and  produce  an  immediate  cardiac  collapse.  I  have  witnessed  such  a 
fatality  three  weeks  after  a  simple  cholecystectomy. 

The  exhausting  taxation  placed  upon  the  heart  when  convalescence  is 
complicated  with  pneumonia,  acute  gastric  dilatation,  ileus,  obstruction, 
or  similar  conditions,  may  create  a  cardiac  collapse. 

The  condition  of  the  heart  and  its  functioning  call  for  constant  watch- 
fulness until  convalescence  is  fully  established. 

Symptoms. — The  presence  of  cardiac  involvement  may  not  be  de- 
tected until  the  patient  is  in  a  state  of  marked  collapse.  In  the  event  of 
such  a  sudden  onset,  our  efforts  toward  revival  are  frequently  futile,  as 
death  rapidly  ensues.  However,  cardiac  stimulants  in  physiologic  doses 
are  indicated. 

When  the  cardiac  exhaustion  is  of  gradual  onset,  there  will  be  noted^a 
slowly  increasing  pulse-rate  with  a  decreased  volume  of  the  pulse  and 
altered  rhythm.     The  pulse  increases  from  100  to  120,  130,  140,  or  160 


128  SURGICAL   NURSING 

and  finally  becomes  uncountable.  This  process  may  gradually  become 
apparent  as  the  heart  weakens  under  its  embarrassment. 

Treatment. — The  treatment  consists  primarily  of  prophylactic  meas- 
ures to  conserve  the  heart's  tone  and  function.  The  patient  should  never 
be  subjected  to  sudden  strains  or  movements.  When  fear  of  heart  exhaus- 
tion exists,  the  patient's  strength  is  to  be  safeguarded.  The  recumbent 
position  is  to  be  insisted  upon.  Strychnin,  digitalis,  stropiianthus,  nitro- 
glycerin, or  similar  cardiac  supports  are  to  be  guardedly  administered. 

Equalization  of  the  circulation  is  to  be  sought  by  the  employment  of 
baths,  rubs,  and  massage.  A  bland,  nourishing  diet  is  indicated.  The 
judicious  employment  of  an  ice  bag  over  the  precordial  region  will  be  found 
of  value.  The  removal  of  the  cause,  in  so  far  as  it  is  possible,  is  of  primal 
importance.  At  best,  the  condition  is  one  of  grave  portent  and  evokes  a 
most  solicitous  concern  and  faithful  nursing. 

DELAYED  HEMORRHAGE 

Delayed  hemorrhage  may  result  from  premature  absorption  of  a  liga- 
ture before  the  severed  end  of  a  blood  vessel  has  been  firmly  sealed;  it  may 
result  from  necrosis  and  sloughing  of  the  wall  of  large  vessels ;  it  is  possible 
in  extensive  wound  infections  or  from  sudden  and  severe  strains  upon  the 
wound.  The  condition  is  detected  by  the  symptoms  of  shock  which 
indicate  the  presence  of  occult  blood  and  by  the  other  symptoms  of  hemor- 
rhage. The  treatment  is  identical  to  that  of  primary  hemorrhage.  De- 
layed hemorrhage  may  occur  from  the  fourth  to  the  fourteenth  day. 

INTESTINAL  OBSTRUCTION 

Intestinal  obstruction  may  attend  any  celiotomy.  It  occurs  by  reason 
of  adhesions,  paralysis  of  the  bowels  from  rough  handling  or  exposure, 
impaction,  intussusception,  a  loop  of  the  intestine  becoming  imprisoned 
in  the  wound  or  around  the  round  ligaments  when  they  are  employed  to 
suspend  the  uterus  and  the  technique  of  prevention  is  not  observed,  and 
from  a  narrowing  of  intestinal  lumen. 

Sjrmptoms. — In  intestinal  obstruction  the  following  symptoms  will  be 
noted: 

Failure  to  secure  satisfactory  bowel  movements  and  passage  of  flatus. 


POST-OPERATIVE    EMERGENCIES  I  29 

Nausea  and  vomiting,  the  latter  becoming  fecal. 

Abdominal  distention. 

Increasing  heart  action  and  eventual  death  if  the  condition  is  not 
promptly  relieved. 

Treatment. — The  treatment  consists  of  the  employment  of  enemas  of 
oil,  salts,  and  glycerin,  milk  of  asafetida,  and  milk  and  molasses.  Eserin, 
pituitrin,  atropin,  and  strychnin  are  indicated  hypodermatically. 

Nothing  is  to  be  given  by  the  mouth  except  small  quantities  of  water. 

The  cause  must  be  sought  and  removed  at  the  onset  of  the  first  signs 
of  the  obstruction.  If  needs  be,  the  abdomen  must  be  reopened  and  the 
release  of  the  bowel  secured.  While  this  may  require  courage,  neverthe- 
less no  reason  exists  for  delaying.  To  successfully  relieve  the  condition 
one  must  allow  a  reasonable  length  of  time  to  secure  results  from  simple 
measures.  Energetic  and  vigorous  methods  should  be  instituted,  but  if, 
after  a  reasonable  elapse  of  time,  the  condition  is  not  controlled,  the  abdo- 
men should  be  reopened  and  the  obstruction  relieved. 

ILEUS 

Ileus  is  a  condition  in  which  there  is  dilatation  of  a  portion  or  alio  f  the 
small  intestine,  distention,  obstruction,  and  toxic  absorption.  With  this 
condition  there  is  a  cardiac  and  a  respiratory  embarrassment  with  more  or 
less  vomiting.  Ileus  may  ensue  after  exposure,  handling,  or  operative 
work  upon  the  intestines.  If  strychnin,  enemata,  gastric  lavage,  pituitrin, 
and  fomentations  fail  to  produce  early  and  prompt  relief,  operative  meas- 
ures are  to  be  employed  and  an  enterostomy  performed. 

ACUTE  GASTRIC  DILATATION 

S5miptoms. — This  serious  complication  may  develop  at  any  time  but  is 
most  frequently  encountered  during  the  first  three  days. 

The  condition  is  due  to  gastric  distention  and  dilatation  by  reason  of 
displacement  or  kinking  and  obstruction  of  the  pylorus.  The  principal 
symptoms  are  pain  and  failing  pulse. 

Persistent  epigastric  pain  is  the  first  complaint  with  more  or  less  epi- 
gastric distention. 

Without  other  cause  the  heart  action  becomes  rapid  and  weak. 


130  SURGICAL   NURSING 

Nausea  and  retching  are  present. 

Death  results  if  the  condition  is  unreHeved. 

Gastric  dilatation  must  not  be  confused  with  intestinal  obstruction  by 
reason  of  the  stomach  manifestations. 

Treatment. — The  treatment  consists  mainly  of  frequent  and  copious 
gastric  lavage  with  normal  saline. 

The  patient's  position  is  to  be  frequently  changed  by  employing  Fow- 
ler's position,  elevation  of  the  head  of  the  bed,  or  even  the  prone  position 
(on  the  stomach). 

All  nourishment  is  to  be  withheld  until  relief  is  accomplished. 

ACUTE  ANURIA :  UREMIA 

This  condition  is  a  grave  complication,  evidenced  by  diminished  or 
complete  lack  of  kidney  secretion  and  the  onset  of  uremic  symptoms.  Its 
prevention  is  more  readily  accomplished  than  is  successful  treatment  after 
it  exists. 

Preventive  Treatment. — The  prophylactic  treatment  consists  of 
knowing  the  functioning  capacity  of  the  kidneys  before  operation,  and 
by  post-operative  proctoclysis.  The  consumption  of  an  abundance  of 
water  is  likewise  to  be  encouraged. 

Treatment.^The  active  treatment  calls  for  free  catharsis,  hot  packs, 
subcutaneous  and  rectal  salines,  and  diuretic  and  circulatory  stimulants. 

Decapsulation  of  the  kidneys  may  be  of  material  aid. 

If  unrelieved  in  reasonable  time,  uremic  symptoms  ensue  and  eventually 
death  closes  the  scene. 

PERITONITIS 

Peritonitis  is  due  to  infection  and  inflammation  of  the  peritoneum. 
When  following  abdominal  section,  it  is  attended  with  a  high  mortality  and 
is  really  the  hete  noire  of  the  abdominal  surgeon.  It  may  occur  at  any 
time  after  the  first  twenty-four  hours — most  often  from  the  second  to  the 
fifth  day. 

Sjnnptoms. — Fever  or  subnormal  temperature. 

Persistent  vomiting. 

Gradually  increasing,  rapid  but  small  pulse. 


POST-OPERATIVE    EMERGENCIES  13I 

Constant  abdominal  pain. 

Tenderness. 
.    Distention  and  signs  of  exhaustion. 

Treatment. — The  treatment  must  be  prompt  and  vigorous  and  consists 
of  draining  the  abdominal  cavity,  saline  cathartics  to  produce  frequent, 
watery  stools,  supportive  measures,  and  local  fomentations.  Our  only 
hope  is  to  produce  elimination,  secure  drainage,  and  foster  the  patient's 
strength  in  the  hope  that  Nature  will  overcome  or  limit  the  infection. 

POST-OPERATIVE  PNEUMONIA 

Surgical  pneumonia  is  like  other  pneumonias  in  its  symptomatology, 
course,  and  treatment.  It  is  a  grave  surgical  complication  that  is  rapidly 
fatal  in  a  large  majority  of  cases.  Recovery,  however,  should  not  be 
despaired  of;  intelligent  treatment  toward  its  relief  should  be  given. 

EXHAUSTION  AND  TOXIC  SINGULTUS 

As  these  terms  imply,  they  comprise  possible  post-operative  emergen- 
cies and  complications.  The  standard  treatment  for  their  relief  is  to  be 
carried  out  in  careful  and  thorough  detail  and  consists  principally  of 
elimination  and  forced  nourishment. 

PERSISTENT  VOMITING 

To  relieve  persistent  vomiting  frequently  tries  our  every  ingenuity. 
It  may  occur  in  one  patient  and  not  in  another  even  though  our  preopera- 
tive preparation  has  been  as  painstaking  for  the  one  as  the  other.  What 
affor'ds  relief  in  one  patient  may  be  entirely  without  result  in  another. 
Again,  the  vomiting  may  cease  spontaneously. 

It  is  commonly  ascribed  to  the  anesthetic  and  the  swallowing  of  anes- 
thetic-laden mucus.  Intra-abdominal  and  gastrointestinal  surgers'  are 
possible  etiological  factors.  The  routine  examination  of  the  gall-bladder 
and  the  expulsion  of  its  entire  contents  into  the  duodenum  by  finger  pres- 
sure may  cause  the  expelled  bile  to  flow  in  such  quantity  into  the  stomach 
as  to  produce  nausea  and  vomiting.  The  injudicious  use  of  morphin  is  a 
productive  factor.  These  and  other  well-known  conditions  induce  this 
unpleasant  and  distressing  state. 


132  SURGICAL   NURSING 

Of  course  one  must  rule  out  gastric  dilatation,  obstruction,  commenc- 
ing peritonitis,  and  ileus. 

Treatment. — The  treatment  is  varied.  Most  effectual  is  gastric 
lavage.'  Drugs  are  of  little  avail.  Early  after  its  onset  if  the  patient  takes 
one  or  two  glasses  of  hot  or  cold  water,  the  stomach  contents  will  be 
expelled,  thus  causing  an  autolavage.  If  the  stomach  is  now  permitted 
to  rest  for  a  few  hours  by  withholding  everything,  the  vomiting  will 
frequently  be  relieved. 

Bits  of  cracked  ice,  carbonated  waters,  carminative  drinks,  bismuth 
in  doses  of  twenty  to  thirty  grains,  soda  mints,  bicarbonate  of  soda,  ginger 
ale,  champagne,  dry  toast,  crackers,  lemon  juice,  castor  oil,  enemata,  and 
morphin  are  all  recommended  and  at  times  productive  of  relief. 

However,  experience  teaches  that  the  less  meddlesome  we  are,  the 
more  speedily  does  the  condition  pass  away.  A  commendable  course  to 
pursue  is  as  follows: 

One  or  two  glasses  of  water,  autolavage. 

Rest  of  the  stomach  for  from  three  to  eight  hours. 

If  not  contraindicated,  give  a  dose  of  morphin  to  secure  sleep  and  rest 
when  the  vomiting  is  unrelieved  and  persistent. 

Withhold  everything  for  twelve  hours. 

If  vomiting  persists  for  twenty-four  hours,  give  gastric  lavage. 

Enemata. 

Polypharmacy  and  pernicious  meddling  should  not  be  resorted  to. 
Autolavage  and  the  withholding  of  everything  for  from  twelve  to  twenty- 
four  hours  comprise  our  chief  procedure. 

PHLEBITIS 

Phlebitis  is  common  during  the  second  or  third  week.  The  condition 
is  considered  as  being. a  septic  one  that  causes  an  inflammation  of  the 
vein  and  formation  of  a  thrombus  which  entirely  or  partially  occludes  its 
lumen. 

S5nnptoms. — Phlebitis  is  ushered  in  by  pain  in  the  leg  and  groin  and  a 
chill  followed  by  a  rise  in  temperature  to  102°  or  104°.  Pain  varies  in 
intensity. 

There  is  tenderness  over  the  course  of  the  femoral  vein  and  especially 
at  Poupart's  ligament. 


POST-OPERATIVE   EMERGENCIES 


133 


The  leg  may  swell  but  little  or  it  may  swell  until  the  skin  is  shining 
from  tenseness. 

Suppuration  may  ensue. 

Treatment. — The  treatment  consists  of  enveloping  the  lim?j  with  cotton 
and  a  bandage.  Elevate  and  surround  it  with  a  moderate  degree  of  local 
heat   (Fig.  87). 


Fig.  84. — Phlebitis.     Entire  Limb  Ex\'eloped  in  Heavy  Layer  of  Cottux. 


Fig.  85. — Phlebitis.     Cotton  Maintained  and  Leg  Snugly  Bandaged  with  Roller  Gauze 

Bandage. 

Painting  the  course  of  the  vein  with  iodin  is  at  times  ordered. 

Massage  of  the  limb  must  never  be  employed,  as  there  is  grave  danger  of 
setting  loose  into  the  blood  stream  fragments  of  the  thrombus  that  may 
become  arrested  in  the  brain,  lungs,  or  heart  and  cause  sudden  death. 


134  SURGICAL   NURSING 

Eventually  the  condition  will  subside  but  convalescence  is  delayed 
two  or  three  weeks. 


Fig.  86. — Phlebitis.     Extreme  Elevation  of  Leg. 


Fig.  87. — Phlebitis.    Leg   Elevated   and    Surrounded   ^^tith   Hot- water   Bottles. 

The  limb  may  never  regain  its  normal  contour,  and  edema  may  persist, 
with  lessened  functional  capacity  of  the  limb. 


POST-OPERATIVE   EMERGENCIES 

Tabulation  or  Common  Post-operative  Complications 


135 


Condi- 
tion 


Cause 


Shock 


Hemorrhage 
Nerve  depression 
Cardiac  exhaustion 


Symptoms 


Onset 


Treatment 


Rapid,  small  pulse 
Semiconsciousness 
Pale,  cold,  clammy  skin 
Subnormal  temperature 


During  operation    Remove  cause,  look  for  hemor- 

ist  and  2d  days         rhage,  camphor  oil,  whiskey, 

morphin,  salines,   local  heat 


Defective  ligation 
Unligated  vessels 
Hemorrhage  '  Ulceration  of  vessel 
wall. 


Shock,  pale  membranes 
Sighing  respiration 
Small,  rapid  pulse 
Restlessness,     cerebral 

anemia 
Bleeding 


Vomiting 


Anuria 


Anesthetic 

Obstruction 

Paresis 

Gastric  dilatation 


Nausea 

Retching 

Vomiting 


During  operation    Arrest  hemorrhage,   morphin, 
First  48  hours        I     salines,     gentle     stimulation, 
5th  to  14th  day         transfusion    of    blood,    heat, 
lower  head,  hematinics 


Recovery     from 
anesthetic 
First  24  hours 


Autolavage,    complete    gastric 
rest,  enemata 


Deficient     kidney  ;  Diminished  secretion  24  to  72  hours 

function  :  Complete  suppression  sth  to  7th  day 

Kidney  disease  j  Increased  pulse,  slowing  as 

j     uremic  symptoms  present 


Prophylaxis,  catharsis,  diu- 
retics, hot  packs,  salines, 
decapsulation 


Ileus 


Intestinal    paralysis  1  As  of  obstruction  _ 
from  exposure  and     Vomiting,   distention,   ris- 
undue  handling         ;     ing  pulse,  prostration 
I  No  bowel  movement 


24  to  72  hours  ;  Enemata,  gastric  lavage,  ca- 
tharsis, pituitrin,  eserin, 
strychnin,  enterostomy  or 
enteroenterostomy 


Acute  gastric 
dilatation 


Displacement 
Pyloric  obstruction 


Epigastric  pain 

Epigastric  distention,  per- 
sistent vomiting,  rising 
pulse 


24  to  72  hours  '  Frequent  gastric  lavage, 
change  of  posture,  strychnin, 
pituitrin,  eserin,  enemata, 
removal  of  cause 


Obstruction 


Adhesions 
Volvulus 
Incarceration 
Impaction 
Narrowed  lumen 


Distention,  no    bowel 

movement 
Vomit  becoming  fecal 
Rising  pulse 
Pain 
Exhaustion 


3d  to  Sth  day  [  Enemata,  pituitrin,  eserin, 
strychnin,  removal  of  ob- 
struction by  prompt,  early 
operative  interference 


Cardiac 
collapse 


Anesthetic 
Prolonged  strain 
Cardiac  disease 
Infections 
Emboli 
Hyperpyrexia 


Failing  and  rapid  pulse 
Circulatory  paralysis 


Any  time 


Removal  of  cause,  quiet,  car- 
diac stimulants,  circulatory 
equalization 


Peritonitis 


Bacterial  infection 
and  soiling  of  the 
peritoneum 


Distention,  obstruction, 
constipation,  vomiting, 
pain,  rising  pulse  140- 
160,  subnormal  tempera- 
ture, Hippocratic  expres- 
sion, exhaustion,  collapse 


2d  to  7th  day  Drainage,    continuous    saline, 

copious  bowel  movements, 
posture,  supportive  treat- 
ment, stimulation 


Emboli    and 
phlebitis 


Thrombic  fragments; 

Fat,  air,  clot 
Septic 


Cardiac 

Respiratory 

Collapse  if  heart  or  brain 

is  reached 
Obstruction  of  vein 


First  48  hours 
7th  to  14th  day 


•  If  vitalpart  is  involved,  treat- 
ment is  valueless 
In  vein — rest,  elevation,  band- 
age, heat,  absolute  quiet  for 
two  weeks,  never  massage 


Sequence  of  Complications 


First 

Second 

Third 

Fourth 

Fifth 

Sixth 

Seventh 

Second 

Day 

Day 

Day 

Day 

Day 

Day 

Day 

Week 

Anesthetic 

Shock 

Hemorrhage 

Acute     dila- 

Ileus 

Peritonitis 

Cardiac 

Phlebitis 

Shock 

Hemorrhage 

Acute  gastric 

tation 

Obstruction 

Septicemia 

Infection 

Emboli 

Hemorrhage 

Vomiting 

dilatation 

Obstruction 

Peritonitis 

Wound     in- 

Pneumonia 

Anuria 

Vomiting 

Acute  gastric 

Vomiting 

Peritonitis 

Pneumonia 

fection 

Obstruction 

Septicemia 

Cardiac 

dilatation 

Ileus 

Anuria 

Cardiac 

Obstruction 

Exhaustion 

Pneumonia 

Ileus 

Obstruction 

Pneumonia 

Secondary 

Cardiac 

Peritonitis 

Cardiac 

Peritonitis 

Peritonitis 

Cardiac 

hemorrhage 

Exhaustion 

Peritonitis 

Anuria 

Anuria 

Septicemia 

Pneumonia 

Hemorrhage 

Cardiac 

Cardiac 

and  wound 

Exhaustion 

Emboli 

Pneumonia 
Emboli 

infection 

1 

These  tabulations  should  serve  as  a  key  that  will  enable  the  nurse  to  early  detect  the  condition,  cause,  and  symp- 
toms, of  post-operative  complications.  From  them  she  will  also  be  enabled  to  direct  the  line  of  nursing  treatment. 
On  the  whole,  they  are  merely  intended  to  put  the  nurse  on  her  guard  and  familiarize  her  with  what  may  happen, 
when  it  may  happen,  and  the  symptoms  that  usher  in  the  complication. 


CHAPTER  X 
THE  PROCESS  OF  HEALING  AND  CARE  OF  WOUNDS 

Wounds  resulting  from  surgical  interference  are  classified  as  incised 
wounds.  They  are  premeditated  and  predetermined  by  the  nature  of  the 
operative  work  that  is  to  be  performed.  As  such,  they  are  repaired,  after 
having  been  produced  to  form  an  avenue  of  approach  to  the  surgical  lesion, 
by  similar  structures  being  coapted  and  held  in  coaptation  by  suture 
material  that  is  introduced  in  compliance  with  the  surgical  principles  of 
repair. 

The  principle  of  coaptation  is  of  but  little  concern  to  the  nurse,  as  her 
province  does  not  include  participation  in  that  procedure.  She  should, 
however,  have  a  general  knowledge  of  the  various  kinds  of  sutures  and 
suture  material.  The  nurse's  relation  to  a  surgical  wound  begins  when  the 
wound  has  been  coapted  by  the  surgeon.  For  this  reason,  she  should  be 
in  possession  of  a  general  working  knowledge  of  the  process  of  repair,  and 
the  deviations  from  the  normal  course  Nature  institutes  to  accomplish 
healing. 

Wounds  are  spoken  of  as  healing  by  first,  second,  or  third  intention. 
This  terminology  is  one  of  long  standing  and  has  been  handed  down  to  us 
by  the  early  pioneers  in  the  surgical  world,  who  reasoned  that  Nature 
always  sought  or  intended  to  accomplish,  the  repair  of  all  wounds,  and  that 
it  was  her  primal  intention  to  cause  a  prompt  healing.  Consequently, 
when  this  was  brought  about  without  delay  or  complication,  the  wound 
was  spoken  of  as  having  healed  by  ''first  intention." 

HEALING  BY  FIRST  INTENTION 

The  process  of  repair  of  wounds  by  first  intention  is  a  physiological 

one,  and  the  following  is  characteristic  of  its  accomplishment. 

When  the  severed  tissues  have  been  aseptically  and  carefully  coapted 

and  protected  by  a  sterile  dressing,  a  small  amount  of  blood  or  serum  flows 

136 


THE  PROCESS  OF  HEALING  AND  CARE  OF  WOUNDS         137 

out  between  the  cut  edges,  rapidly  clots,  and  thus  seals  up  the  openings 
and  spaces.  Migrating  blood  corpuscles  pass  into  this  newly  formed 
clot  and  into  the  tissues.  Connective  tissue  and  endothelial  cells  are  now 
formed  and  produce  new  tissue.  These  cells  are  known  as  fibroblasts  and 
they  absorb  the  corpuscles  that  were  first  thrown  out;  by  multiplying  and 
interlacing  they  completely  fill  up  the  minute  spaces  that  exist  in  the 
wound  area.  Capillaries  then  appear  in  this  new  connective  tissue  and 
the  entire  mass  is  now  recognized  as  "being  organized."  The  interlacing 
fibroblasts  develop  new  fibers  and  when  this  process  of  development  is 
complete  the  tissue  formed  is  termed  fibrous  tissue.  These  fibers  com- 
mence to  contract  and  obliterate  the  capillaries  by  pressure.  Epithelial 
cells  are  then  developed  and  serve  to  close  the  skin  edges.  Cicatrization 
next  occurs  and  consists  of  the  formation  of  new  fibrous  tissue  which 
finally  contracts  and  so,  by  reason  of  its  contraction,  forms  that  w^hite, 
tough  tissue  commonly  spoken  of  as  scar  tissue.  This  process  is  usually 
accomplished  with  but  little  local  disturbance  and  swelling,  although 
occasionally  there  develops  some  swelling,  redness,  and  circulatory  stasis. 
Summarized,  the  normal  process  of  healing  by  first  intention  consists  of : 

Clotted  blood.  Contracted  fibrous  tissue. 

Coagulated  exudate.  Scar  tissue. 

Proliferating  cells.  ,  Complete  union. 

Fibrous  tissue. 

HEALING  BY  SECOND  INTENTION 

The  healing  process  may  be  retarded  or  entirely  prevented  by  the  pres- 
ence or  entrance  of  bacteria  in  such  numbers  as  to  render  healing  by  first 
intention  impossible.  When  such  a  complication  is  encountered,  the 
healing  of  the  wound  then  becomes  dependent  upon  Nature's  second 
method,  that  of  healing  by  second  intention  or  healing  by  granulation. 
This  is  accomplished  in  much  the  same  manner  as  union  by  first  intention. 

The  bacterial  infection  causes  a  peptonization  of  the  intracellular  sub- 
stance, many  reparative  cells  are  carried  off,  and  repair  can  only  be  effected 
by  an  enormous  formation  of  fibroblasts.  Soon  after  the  closing  of  the 
wound  the  oozing  ceases,  because  thrombi  form  in  the  vessels  and  clots 
gather  in  the  tissue  gaps  and  interstices.     Exudation  begins,  and  leucocytes 


138  SURGICAL   NURSING 

migrate  into  the  exudate  and  the  walls  of  the  wound.  In  a  short  time 
the  wound  becomes  distinctly  glazed,  or  glistening,  because  of  the  for- 
mation of  coagulation  fibrin.  The  exudate  is  at  first  thin  and  red  and 
soon  becomes  very  profuse.  In  a  few  days  the  discharge  becomes  puru- 
lent. The  connective  tissue  cells  proliferate  and  form  fibroblasts,  which 
multiply  to  close  the  wound.  From  adjacent  capillaries  new  capillaries 
form  and  run  between  the  fibroblasts.  When  the  discharge  becomes 
purulent  and  leucocytes  and  fibroblasts  are  destroyed,  inflammation 
increases,  exudation  becomes  profuse,  and  new  cells  are  rapidly  formed 
to  make  up  for  the  loss  caused  by  microbic  action. 

Gradually  the  gap  is  filled.  As  it  is  being  filled,  the  older  fibroblasts 
in  the  deeper  layers  and  edges  of  the  wound  are  converted  into  cicatricial, 
fibrous,  or  scar  tissue.  As  the  granulations  rise  to  a  higher  level  at  the 
surface,  the  area  of  fibrous  tissue  becomes  broader  at  the  base  and  margins, 
and  in  this  young  fibrous  tissue  contracts.  The  contraction  draws  the 
edges  of  the  wound  nearer  together,  and  thus  lessens  the  area  of  the  surface 
which  must  be  covered  with  epithelium.  When  the  granulations  reach 
the  level  of  the  cutaneous  surface,  the  epithehal  cells  at  the  margin  of  the 
wound  proliferate  and  the  skin  covering  is  formed. 

If  the  granulations  rise  above  the  cutaneous  level,  healing  will  not  take 
place,  because  the  epithelium  cannot  then  grow  over  the  raw  surface.  A 
wound  in  this  condition  is  said  to  possess  exuberant  granulations,  or  proud 
flesh.  This  formation  must  be  destroyed  and  held  in  restriction  until  the 
raw  surface  is  covered  with  epithelium. 

The  wound  healed  by  second  intention  undergoes  scar  contraction  the 
same  as  primarily  healed  wounds. 

HEALING  BY  THIRD  INTENTION 

This  consists  of  the  union  of  two  granulating  surfaces,  the  granulations 
of  one  side  fusing  with  those  of  the  other.  It  is  seen  in  the  union  of  col- 
lapsed abscess  walls.  The  granulations  are  formed  as  in  healing  by  second 
intention. 

SCARS 

Healed  wounds  may  present  a  narrow  red  surface  which  may,  when 
the"' dressings  are  finally  discarded,  gradually  broaden  by  reason  of  the 


THE   PROCESS    OF   HEALING   AND    CARE    OF   WOUNDS 


139 


stretching  that  takes  place  in  the  new  epitheUum  that  forms  the  skin. 
This  redness  will  gradually  disappear,  and  a  white  area,  varying  from  a 
mere  line  to  a  quarter  of  an  inch  or  more  in  width,  is  the  only  remaining 
visible  evidence  of  operative  entrance.  Patients  will  frequently  worry 
over  this  broadening  process  but  little  occasion  exists  for  uneasiness. 

Most  scars  are  insensitive,  some  are  hypersensitive.  The  hyper- 
sensitive scars  are  usually  thin  and  pale.  The  itching,  burning,  or  tin- 
gling experienced  in  a  sensitive  scar  is  lo- 
cated, as  a  rule,  at  the  junction  of  sound 
skin  and  the  newly  formed  epidermis. 
The  unpleasant  sensations  result  from 
pressure  upon  the  nerve  filaments  in  the 
uninjured  skin.  The  sensitiveness  and 
itching  of  the  scar  may  be  relieved  by 
frequent  bathing  with  alcohol. 

A  scar  may  become  inflamed,  warts 
may  spring  from  its  cutaneous  surface, 
keloids  may  arise  from  its  fibrous  tissue, 
carcinoma  may  come  from  the  epithelial 
elements,  sarcoma  from  the  connective- 
tissue  elements.  These  are  all  possibil- 
ities, but  happily  they  do  not  appear  in 
a  large  majority  of  the  cases. 

In  abdominal  incisions  the  peritoneum 
and  skin  may  firmly  unite,  but  on  account  of  improper  coaptation, 
infection,  the  too  rapid  absorption  of  suture  material,  strains,  or 
an  imperfect  process  of  repair,  the  muscles  and  fasciae  do  not  unite 
or  unite  only  in  part.  In  this  event,  the  pressure  of  the  intestines 
will  cause  a  stretching  of  the  peritoneum,  and  one  or  more  coils 
of  intestine  will  protrude  through  the  defective  wall,  thus  forming  a  ven- 
tral hernia.  When  a  ventral  hernia  occurs,  it  should  be  repaired  at  once 
by  a  herniotomy. 

A  ventral  hernia  is  very  apt  to  occur  after  drainage  has  been  employed, 
for  this,  of  course,  makes  it  impossible  to  coapt  the  wound  in  its  entirety. 
This  should  be  borne  in  mind,  and  the  patient  warned  of  the  possibility. 


Fig.     88. 


Appen- 


A      Satisfactory 
DECTOMY  Scar. 
Shows  scars  of   incision,   of   two   ten- 
sion sutures,  and  of  catgut  skin  sutures. 
Two  years  after  operation. 


140  SURGICAL   NURSING 

Frequently  patients  will  resort  to  abdominal  supports  for  many  weeks. 
Such  a  precaution  is  no  longer  deemed  necessary.  If  an  abdominal  wound 
has  fully  and  firmly  healed,  a  belt  or  support  is  seldom  required;  on  the 
contrary,  if  a  wound  has  not  firmly  united,  a  support  will  not  correct  the 
defect. 

It  is  our  custom  to  advise  that  the  corset  be  worn  just  as  soon  as  the 
wound  is  healed  and  the  patient  permitted  to  be  up  the  major  portion  of 
the  day.  As  there  is  no  reason  for  not  wearing  it  after  the  wound  is  healed, 
the  patient  may  exercise  her  own  judgment. 

In  the  preparation  of  the  preceding  treatise  on  the  healing  of  wounds, 
the  author  has  condensed  from  "Repair  of  Wounds"  in  DaCosta's 
Modern  Surgery,  published  by  W.  B.  Saunders  Company.  The  student 
desirous  of  possessing  a  greater  knowledge  of  the  process  instituted  by 
Nature  to  repair  wounds  is  referred  to  the  standard  textbook  on  pathology 
and  surgery. 

THE  CARE  OF  WOUNDS 

What  care  should  a  surgical  wound  receive?  It  is  our  purpose  to  so 
discuss  this  phase  of  the  subject  that  it  may  serve  as  a  general  guide  to  the 
nurse. 

In  our  previous  chapters  we  have  briefly  described  some  of  these  pro- 
cedures in  order  that  the  subject  under  discussion  might  be  more  lucidly 
presented.  In  order  that  our  present  discussion  may  not  be  disconnected, 
it  is  necessary  to  repeat  some  of  the  information  previously  given. 

The  last  suture  tied,  the  wound,  if  a  clean  one  and  not  drained,  must 
be  protected  by  an  aseptic  dressing  that  serves  two  purposes,  protection 
and  support;  protection  from  outside  contamination  which  would  prevent 
uninterrupted  healing,  and  support  to  remove  strain  or  undue  tension  upon 
the  suture  material. 

Not  so  very  long  ago  it  was  common  practice  to  first  apply  some  one  of 
the  many  so-called  dusting  or  antiseptic  powders.  Experience  has  shown 
that  the  use  of  these  powders  is  of  little  value  in  aiding  repair  or  preventing 
infection.     They  are  now  but  rarely  employed. 

The  surrounding  skin  area  is  cleansed  from  blood  stains  with  a  sponge 


THE  PROCESS  OF  HEALING  AND  CARE  OF  WOUNDS        141 

moistened  either  with  sterile  water  or  alcohol.  The  wound  and  the  sur- 
rounding skin  are  then  thoroughly  dried  with  sterile  gauze,  and  the  dressing, 
consisting  of  sterile  gauze  folded  into  convenient  sizes,  applied.  If  tension 
sutures  have  been  employed,  gauze  is  placed  on  either  side  of  the  wound  to 
prevent  the  ends  of  the  sutures  from  irritating  the  skin.  Another  gauze 
dressing  is  then  placed  over  the  center  of  the  wound,  and  is  followed  by 
three  or  more  dressings,  thus  forming  a  second  layer  over  that  previously 
applied.  The  whole  is  then  maintained  in  place  by  adhesive  straps  fas- 
tened at  the  top  and  bottom  of  the  dressings.  These  straps  serve  two 
purposes:  they  prevent  the  dressings  from  becoming  dislodged  and  also 
prevent  the  patient  from  inserting  her  fingers  under  the  dressing  and  thus 
contaminating  the  wound.  Over  this  dressing  is  placed  a  filled  pad  which 
is  held  in  place  by  adhesive  tapes.  A  Scultetus  bandage,  appHed  rather 
snugly,  completes  the  dressing. 

In  head  dressings  or  in  dressings  of  the  extremities  the  same  method  is 
followed  except  that  the  filled  pad  may  be  discarded  and  cotton  used 
instead,  and  a  roller  bandage  displaces  the  binder. 

In  wounds  which  contain  drainage  and  in  those  which  require  frequent 
change  of  dressings,  the  adhesive  straps  are  not  employed.  In  such 
drained  wounds  a  large  quantity  of  fluff  gauze  that  readily  absorbs  the 
wound  discharge  will  be  found  most  suitable. 

Some  surgeons  apply  a  silver  foil  directly  to  the  wound  before  applying 
the  gauze  dressings;  others  seal  the  wound  with  collodion;  another  practice 
is  to  cover  the  wound  with  a  double  layer  of  gauze  and  seal  its  edges  to  the 
skin  with  collodion.  Some  clinics  employ  a  large  quantity  of  fluff  gauze 
which  is  applied  directly  to  the  wound  and  maintained  in  place  with  a 
broad  strap  of  adhesive  plaster. 

Draining  wounds  require  frequent  change  of  dressings,  and  this  duty 
is  often  assigned  to  the  nurse.  These  wounds  are,  as  a  rule,  partly  sutured. 
The  purulent  discharges  will  tend  to  cause  infection  and  break  down  the 
sutured  portion.  This  may  often  be  prevented  by  cleansing  the  sutured 
area  with  70  per  cent,  alcohol  when  changing  the  dressings  and  applying 
gauze  moistened  with  the  same  strength  of  alcohol. 

The  drainage  material  commonly  consists  of  rubber  tubing,  cigarette 


142  SURGICAL   NURSING 

drain,  or  gauze.  When  a  rubber  tube  is  employed  it  should  be  turned  fre- 
quently to  prevent  pressure  necrosis  of  the  tissue  it  rests  against.  Such 
necrosis  may  cause  ulceration  into  a  large  vessel,  with  severe  hemorrhages. 

Drainage  material  has  very  frequently  become  lost  in  the  abdominal  or 
thoracic  cavity.  To  guard  against  this  misfortune,  drains  should  be 
anchored  by  a  large  safety  pin  inserted  through  the  outer  end  if  the  surgeon 
has  not  anchored  them  with  a  suture.  The  drain  should  never  be  removed 
by  the  nurse  without  direct  instructions  from  the  surgeon. 

Wounds  that  are  drained  heal  by  granulation.  When  the  purulent 
discharge  commences  to  lessen,  the  drainage  tube  is  gradually  removed  by 
shortening  its  length  every  day  or  two.  Finally,  it  is  entirely  withdrawn 
and  gauze  packing  is  used  to  lead  off  the  discharge.  This,  in  turn,  is 
withdrawn  so  that  eventually  the  wound  becomes  healed  by  fusion  of 
the  granulations.  The  attention  is  directed  principally  to  keeping  the 
wound  clean  and  changing  the  dressings  frequently  so  that  the  external 
surface  does  not  remain  bathed  in  the  discharge. 

Certain  drugs  or  solutions  are  frequently  employed  to  stimulate  the 
growth  of  granulations.  The  two  most  generally  used  are  balsam  of 
Peru  and  solutions  of  nitrate  of  silver  in  strengths  of  lo  to  60  grains  to  an 
ounce  of  water.     The  caustic  stick  is  also  employed. 

As  the  granulations  approach  the  level  of  the  skin,  the  wound  may  be 
drawn  together  by  means  of  adhesive  straps  to  favor  and  hasten  the  union 
of  the  skin. 

In  an  aseptic  operation  in  which  the  incision  has  been  completely  su- 
tured without  the  use  of  drainage,  the  surgeon  does  not  resort  to  frequent 
inspections  to  ascertain  whether  or  not  union  is  occurring  by  first  inten- 
tion. In  such  cases  the  temperature,  pulse,  and  the  patient's  descriptions 
of  the  sensations  experienced  in  the  wound  are  the  signs  on  which  he  bases 
his  opinion  as  to  whether  an  infection  or  satisfactory  union  is  taking  place. 

Clean  wounds,  or  those  healing  by  first  intention,  are  rarely  disturbed 
until  a  week  or  ten  days  have  elapsed.  The  suture  may  or  may  not  be 
removed  at  the  first  inspection. 

The  patient's  post-operative  temperature  should  attain  a  normal  regis- 
ter on  or  about  the  fourth  day.     If,  on  the  morning  of  the  fourth  day,  we 


THE    PROCESS    OF    HEALING    AND    CARE    OF    WOUNDS  I43 

find  the  patient  registering  a  normal  temperature  and  at  four  or  six  o'clock 
in  the  afternoon  a  temperature  of  99.6°  to  100.5°,  with  a  corresponding 
pulse,  followed  on  the  fifth  morning  by  a  temperature  of  98.6°  or  99°  and  an 
afternoon  record  of  100.5°  or  even  higher,  we  may  safely  conclude  that 
some  infective  absorption  is  occurring.  These  symptoms  call  for  inves- 
tigation to  determine  whether  there  is  some  other  condition  present  to 
account  for  the  temperature  elevation.  It  frequently  occurs  that  the 
afternoon  temperature  on  the  fourth,  fifth,  and  sixth  post-operative  days 
may  be  99°  to  99.6°  and  the  wound  still  found  to  be  sterile. 

Again,  although  the  temperature  may  not  reach  over  99.4°,  with  pulse 
within  bounds,  the  patient  may  complain  of  stinging,  burning,  and  sore- 
ness in  the  wound  that  at  times  is  very  painful  and  annoying.  Such  a 
condition  also  calls  for  investigation. 

The  soiling  of  the  dressings  or  the  appearance  of  a  discharge  under  the 
sides  of  the  dressing  likewise  demands  prompt  investigation  even  though 
the  temperature  and  pulse  be  normal. 

When  infection  has  occurred  in  a  clean  wound  it  is  treated  as  an  infected 
wound.  The  sutures  may  be  entirely  or  only  partly  removed,  the  wound 
thoroughly  cleansed,  frequently  swabbed  with  iodin,  and  a  moist  alcohol 
dressing  applied.  It  is  then  the  surgeon's  endeavor  to  cause  healing  by 
second  intention.  Often  extensive  infection  occurs,  with  sloughing  of 
skin,  fascia,  and  even  muscle,  so  that  repair  is  a  long-drawn-out 
process. 

When  a  wound  which  we  have  every  reason  to  believe  should  have 
united  by  first  intention  becomes  infected,  every  procedure  of  the  operation 
should  be  checked  over  to  ascertain  where  the  break  in  our  chain  of  aseptic 
technique  occurred,  in  order  to  avoid  such  an  error  in  the  future. 

While  the  theory  is  advanced  that  infection  may  arise  from  within  or  be 
introduced  from  without,  a  break  in  the  chain  of  asepsis  during  the  opera- 
tion may  be  credited  as  the  most  frequent  cause. 

REQUIREMENTS  FOR  A  DRESSING 

The  "doing  of  a  dressing,"  while  comparatively  simple,  calls  for  a 
definite  procedure  to  conserve  the  time  of  the  surgeon  performing  it. 


144 


SURGICAL   NURSING 


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THE    PROCESS    OF    HEALING    AND    CARE    OF    WOUNDS  1 49 

When  a  nurse  knows  that  a  dressing  is  to  be  done  or  sutures  removed  she 
should  prepare  the  foUowing  articles  (Fig.  80) : 

Sterile  towels  and  gloves. 

Instruments,  consisting  of  scissors,  grooved  director,  tissue  forceps,  and  probe,  all  to  be  sterilized 
by  boiling. 

Sterile  dressings.     Adhesive  plaster. 
Packing  or  drainage  material. 
Solutions  and  70  per  cent,  alcohol. 
Paper  bag  to  receive  soiled  dressings. 

While  the  surgeon  is  preparing  his  hands  the  nurse  prepares  the  patient. 
After  removing  the  binder,  the  field  is  surrounded  with  the  sterile  towels, 
the  tapes  are  untied,  the  pad  removed,  and  the  adhesive  straps  holding  the 
proximal  dressing  loosened ;  these  dressings  are  not  removed.  The  patient 
is  instructed  to  keep  her  hands  above  her  head.  The  contents  of  the 
sterile-dressing  package  are  laid  upon  the  sterile  towels  so  that  they  will 
not  come  in  contact  with  the  nurse's  hands  and  thus  be  rendered  un- 
sterile.  The  basin  containing  the  instruments  is  placed  within  convenient 
reach.     The  nurse  now  directs  her  attention  to  waiting  upon  the  surgeon. 

The  surgeon  will  remove  the  proximal  dressings  and,  if  he  deems  proper, 
the  sutures.  He  will  then  cleanse  the  wound  with  alcohol  and  reapply  the 
dressings. 

If  it  is  a  dressing  in  which  drainage  is  employed,  the  surgeon  will 
cleanse  the  wound  with  the  preferred  solution,  probably  irrigate  it,  and 
perhaps  apply  a  stimulating  lotion  or  repack  it  with  gauze. 

As  a  container  for  soiled  dressings,  nothing  is  as  convenient  as  an 
ordinary  paper  sack.  When  the  dressing  is  completed,  the  bag  in  which 
the  soiled  material  has  been  placed  may  be  destroyed  in  the  stove  or 
furnace. 

The  nature  of  the  dressing  will  determine  whether  the  nurse  should 
have  in  readiness  an  irrigating  syringe  and  solution,  the  desired  drainage 
or  packing  material,  or  such  other  supplies  as  the  surgeon  indicates. 

Whenever  the  surgeon  or  the  nurse  performs  a  dressing,  record  should 
be  made  on  the  chart  of  the  time  the  dressing  was  done,  who  performed  it, 
the  condition  of  the  wound,  the  nature  and  amount  of  discharge,  and  the 
progress  of  healing.  When  sutures  are  removed,  the  item  should  be 
entered  on  the  chart. 


1^0  SURGICAL   NURSING 

In  this  chapter  we  have  endeavored  to  present  the  subject  under  discus- 
sion in  a  general  way.  The  nurse  who  f amiharizes  herself  with  this  infor- 
mation will  be  able  to  inteUigently  observe  the  progress  of  the  process  of 
repair  and  aid  the  surgeon  and  patient  to  expedite  the  heahng  process. 
Individual  cases,  to  be  sure,  will  demand  varied  care,  but  as  a  rule  the 
procedure  will  conform  to  the  general  principles  that  have  been  advanced. 


CHAPTER  XI 
ANESTHESIA 

The  facts  and  historical  details  surrounding  the  discovery  of  an  anes- 
thetic agent  and  its  primal  demonstration  in  Boston  in  1846  are  so  well 
known  to  each  individual  in  any  way  immediately  connected  with  surgery 
and  its  operative  technique  that  it  is  unnecessary  to  discuss  this  phase  of 
the  subject.  That  which  concerns  us  most  is  what  the  experiences  of  the 
past  have  taught  us,  what  anesthetic  agent  is  the  one  of  choice,  and  what 
our  duty  is  during  its  administration. 

From  the  voluminous  literature  upon  the  subject,  based  upon  the 
records  of  administration  in  thousands  and  thousands  of  cases,  there  has 
been  evolved  a  fairly  universal  unanimity  of  opinion,  and  by  the  light  of 
that  experience  we  are  enabled  to  lay  down  dependable  facts  to  guide  our 
procedures. 

Experimental  excursions  have  been  made  in  many  directions.  Com- 
binations of  chemical  substances  have  been  compounded,  used,  and  ulti- 
mately discarded.  Apparatus  varied  in  styles,  principles,  and  purposes 
have  been  invented,  exploited,  and  cast  into  the  junk  pile. 

Preanesthetic  medication  and  complicated  antagonists  and  incom- 
patibles  have  been  recommended  only  to  be  finally  condemned.  New 
avenues  of  introducing  the  anesthetic  into  the  system  have  been  suggested 
and  found  wanting  or  impracticable.  Thus  has  the  pendulum  s^\'ung  to 
and  fro  in  the  eager  search  and  enthusiastic  attempt  to  cast  the  old  aside 
for  something  new. 

These  investigations,  experiments,  and  discussions  have  had  their 
value  and  serve  to  enable  us  to  make  definite  deductions.  They  justify 
the  present-day  attitude  toward  the  anesthetic  of  choice  and  safet}'  and  its 
mode  of  administration.  We  are  enabled  thereby  to  make  authoritative 
statements  to  our  patients. 

Without  entering  into  a  minute  discussion  of  the  agents  or  methods 

151 


152  SURGICAL   NURSING 

of  administration,  it  will  be  my  purpose  to  impart  working  and  essential 
facts  regarding  the  more  frequently  employed  agents  and  their  method 
of  administration. 

ETHER 

Ether  is  conceded  to  be  the  safest  anesthetic  agent  known.  The 
death  rate  following  its  administration  is  from  i  in  5000  to  i  in  10,000. 
It  is  best  administered  by  what  is  known  as  the  open  method — with  an 
abundance  of  air.  Its  administration  by  experts  eliminates  all  the  un- 
pleasantness that  has  been  attributed  to  it.  Its  after-effects  may  also  be 
reduced  to  but  transient  states  of  minor  concern. 

Ether  should  be  slowly  administered  with  an  abundance  of  air  and 
never  crowded.  Fifteen  to  twenty  minutes  should  be  utilized  in  producing 
a  state  of  complete  anesthetization  in  a  patient. 

Its  use  should  be  preceded  by  a  hypodermic  of  atropin,  grain  Mso, 
combined  with  small  doses  of  morphin  unless  a  distinct  counterindication 
exists  to  the  use  of  this  adjuvant. 

Ether  should  never  be  administered  in  a  room  in  which  there  is  any 
open  fire  or  flame,  as  its  volatility  may  cause  an  explosion  or  fire. 

CHLOROFORM 

Chloroform  today  is  regarded  as  the  most  dangerous  of  anesthetics; 
it  is  attended  with  a  death  rate  of  i  in  1000  to  i  in  3000.  Were  it  not  for 
this  high  mortality,  chloroform  would  at  once  become  the  agent  of  supreme 
choice  by  reason  of  its  other  qualities  of  efficiency,  comfort,  and  simplicity. 
It  is  these  qualities  that  have  caused  its  extensive  employment  in  the  past. 
However,  the  fatalities  of  the  past  conclusively  force  us  to  declare  that  the 
time  is  at  hand  when  chloroform  must  absolutely  be  discarded.  One 
is  no  longer  ever  justified  to  resort  to,  or  continue  in  its  use. 

NITROUS  OXIDE  GAS 

Next  to  ether,  nitrous  oxide  gas  anesthesia  commends  itself.  Its 
use,  however,  is  limited  in  many  respects. 

The  foregoing  are  the  three  anesthetic  agents  employed  and  from 
that  group  chloroform  must  be  removed.     Of  the  remaining  agents  ether 


ANESTHESIA  1 53 

has  been  introduced  into  the  system  by  the  intravenous,  rectal,  and  in- 
tratracheal insufflation  routes  singly  or  combined  with  other  agents. 

At  present  our  attitude  is:  Ether  for  major  and  prolonged  surgical 
procedures;  gas  for  short  anesthesias  or  in  urinary  insufficiency. 

Much  has  been  said  lately  in  regard  to  scopolamin  and  morphin — 
"twilight  sleep" — alone  or  preceding  ether.  The  profession  is  agreed 
that  it  is  a  dangerous  and  unreliable  agent. 

SPINAL  ANESTHESIA 

Spinal  anesthesia  has  been  demonstrated  to  be  more  dangerous  than 
chloroform  and  is  accredited  with  one  death  in  every  five  hundred  ad- 
ministrations. This  obviates  the  necessity  of  further  discussion,  as  it 
is  too  dangerous  to  merit  a  place  in  surgery. 

LOCAL  ANESTHESIA 

With  the  advent  of  novocain  the  employment  of  local  anesthetics 
received  a  marked  impetus.  Properly  administered  it  is  practically  devoid 
of  all  unpleasantness  and  dangers.  It  is  indicated  in  numerous  conditions 
and  the  more  one  becomes  conversant  with  its  possibilities  the  more  fre- 
quently it  is  employed ;  operations  of  great  magnitude  are  performed  with 
its  aid. 

To  understanding^  use  and  inject  it  one  must  be  thoroughly  con- 
versant with  the  anatomical  distribution  of  the  nerves  supplying  the  part 
subjected  to  surgical  entrance. 

While  various  combinations  of  drugs  have  been  used  with  novocain 
the  employment  of  simple  normal  saline  as  a  dissolvent  to  the  strength 
of  0.25  to  0.5  is  most  satisfactory.  In  this  strength  six  to  eight  ounces 
have  been  injected  with  no  untoward  effects.  Adrenahn  or  epinephrin 
may  be  added  to  this  solution  but  should  never  be  employed  in  strengths 
exceeding  i  in  200,000. 

The  solution  when  administered  must  be  sterilized.  This  is  accom- 
plished by  boihng  for  a  period  not  to  exceed  ten  minutes.  Stock  solutions 
■  are  unsatisfactory.     A  fresh  solution  is  preferable. 

While  rectal,   intrapharyngeal,  intratracheal,   intravenous  routes  of 


154  SURGICAL  NURSING 

administration  are  employed  and  various  mixtures  and  sequences  are 
utilized  by  various  surgeons  and  clinics,  their  purposes  and  technique  of 
administration  are  so  complicated  and  entail  such  extensive  experience, 
that  it  is  unnecessary  to  enter  into  a  description  of  these  anesthetic 
bypaths. 

Bevan^  has  most  admirably  summed  up  the  present-day  attitude  of 
surgeons  in  the  determination  of  the  choice  of  anesthetic  as  follows: 

1.  Drop  ether  should  today  be  chosen  as  the  standard  general  anes- 
thetic when  a  prolonged  anesthetic  is  desired  with  relaxation  and 
unconsciousness. 

2.  Intrapharyngeal  ether  should  be  chosen  in  mouth  and  jaw  cases 
when  it  is  desirable  to  remove  the  anesthetist  and  anesthetic  apparatus 
from  the  operative  field. 

3.  Gas  should  be  chosen  in  short  anesthesias  in  which  unconsciousness 
is  desired,  and  in  special  cases,  such  as  kidney  insufficiency. 

4.  Local  infiltration,  anesthesia  should  be  chosen  when  the  surgeon  has 
the  full  cooperation  of  the  patient  and  the  field  of  operation  can  be 
completely  anesthetized. 

The  Duty  of  the  Nurse.— Formerly  it  was  the  custom  to  delegate  a 
nurse  to  the  sole  duty  of  watching  and  recording  the  pulse  of  the  anesthe- 
tized person  and  to  report  its  quality  and  rapidity  to  the  administrator. 
With  the  advent  of  trained  and  skilled  anesthetists  the  "nurse-sentinel" 
was  discharged.  The  trained  anesthetist  exercises  a  watchful  alertness 
for  danger  signs  and  warning.  It  is  only  when  serious  emergencies  arise 
that  the  nurse  is  called  upon  to  render  assistance,  and  her  efforts  are  always 
subservient  to  the  orders  of  the  anesthetist. 

She  will  be  called  upon  to  administer  the  indicated  respiratory  or 
circulatory  stimulant.  The  stimulating  drugs  most  commonly  employed 
are  camphor  oil,  whiskey,  strychnin,  digitalin,  nitroglycerin,  adrenalin 
and  atropin.  They  are  given  hypodermatically.  Saline  either  subcutane- 
ously  or  intravenously  is  frequently  resorted  to,  and  the  nurse  should  be 
able  to  rapidly  undertake  the  necessary  preparatory  steps  for  its  adminis- 
tration.    Artificial  respiration  may  be  necessary  but  will  probably   be 

1  Jour.  A.  M.  A.,  Vol.  LXV,  No.  17. 


ANESTHESIA  1 55 

undertaken  by  the  anesthetist  and  surgeon.  Rectal  dilatation  and  stimu- 
lating enemata  may  likewise  be  resorted  to,  but  the  desired  fluid  will  be 
indicated  by  the  anesthetist  or  surgeon  and  its  administration  supervised. 

Fortunately,  collapse  from  oversaturation  by  the  anesthetic  agent  is 
being  met  less  frequently  by  reason  of  skilled  administration,  and  emer- 
gency methods  of  resuscitation  are  now  but  rarely  needed.  The  impor- 
tance of  having  a  skilled  and  experienced  anesthetist  is  receiving  greater 
recognition  and  as  we  insist  upon  his  employment  the  emergency  need  of 
instituting  resuscitating  measures  will  become  less  frequent.  A  competent 
anesthetist  is  as  important  as  a  competent  surgeon.  The  excuse  of  em- 
ploying an  incompetent  anesthetist  is  but  rarely  justified. 

Post-anesthetic  Distress. — In  spite  of  careful  preoperative  prepara- 
tion, skilled  administration,  and  minimum  dosage,  we  meet  with  varying 
frequency  certain  post-anesthetic  distress,  foremost  of  which  is  the  nausea 
and  vomiting.  One  patient  will  give  but  transient  and  brief  evidence  of 
such  discomfort  while  another  will  be  extremely  depressed  and  distressed 
by  stomach  irritation. 

Patients  will  likewise  be  met  who  suffer  from  intense  headache  follow- 
ing the  return  of  consciousness.  With  the  headache,  complaint  will  also 
be  made  of  some  deafness,  ringing  in  the  ears,  and  possibly  some  evidence 
of  delirium.  Herpes  of  the  mouth  and  nares  may  appear.  A  con- 
junctivitis, if  the  eyes  were  not  protected,  may  be  present  and  be  produc- 
tive of  extreme  discomfort.  There  are  also  certain  physical  discomforts, 
such  as  backache  and  arm  and  leg  crampings. 

In  addition  there  is  encountered  pharyngolaryngitis,  bronchitis,  and 
pneumonia  due  to  the  inhalation  of  the  anesthetic  vapor. 

There  will  be  found  those  who  are  hysterical,  exalted,  elated,  talkative, 
or  dejected  for  periods  of  varying  length.  Likewise  there  will  be  met  the 
pugnacious,  ugly  individual  who  requires  restraint. 

Enumerated,  the  post-anesthetic  distresses  consist  of  inflammation  of 
the  eyes,  throat,  and  lungs,  nausea,  vomiting,  herpes,  mental  exaltations 
or  depressions,  backache,  and  muscle  crampings.  The  indicated  treat- 
ment for  these  several  conditions  has  been  enumerated  under  post- 
operative care. 


CHAPTER  XII 
THE  NURSE'S  CHART  IN  SURGICAL  CASES 

The  nurse's  chart  and  record  in  a  surgical  case  should  be  more  than 
merely  a  few  notations  recording  temperature,  pulse,  respiration,  and 
bowel  movements  in  addition  to  other  disconnected  notations  of  the 
patient's  post-operative  progress.  A  chart  should  be  so  prepared  as  to 
impart  intrinsic  information  that  is  of  value  to  the  attending  surgeon  and 
physician,  and  thus  accurately  and  in  detail  enlighten  them  as  to  their 
patient's  condition  during  every  hour  that  has  elapsed  since  their  last  visit. 

A  nurse  is  often  judged  by  the  chart  that  she  keeps.  It  often  reflects 
the  training  that  a  nurse  has  received.  Further,  it  imparts  to  the  surgeon 
evidence  as  to  whether  or  not  his  patient  is  under  the  care  of  a  careful, 
observing,  and  intelligent  nurse,  or  one  who  lacks  these  qualifications. 
As  such,  it  is  then  of  greatest  importance  that  every  nurse  make  it  one  of 
her  first  duties  to  observe  and  concisely,  yet  distinctively,  record  in 
consecutive  order  the  salient  and  important  symptoms,  observations,  and 
treatment  that  is  administered  during  the  time  that  passes  between  the 
visits  of  the  surgeon. 

This  is  a  matter  that  is  often  overlooked.  Weariness  and  long  ex- 
hausting hours  of  constant  vigilance  with  every  moment  occupied,  tend 
to  beget  carelessness  with  resultant  meager,  often  meaningless,  records. 
These  deficiencies  may  be  overcome  if  the  nurse  will  but  remember  the 
essentials  of  charting,  and,  by  following  a  definite  plan  and  the  use  of  a 
few  descriptive  adjectives,  record  her  observations  and  work.  It  must 
be  remembered  that  a  chart  is  to  be  a  complete  and  detailed  record  of 
a  patient's  illness  and  that  to  be  of  value  it  must  impart  intelHgent 
information. 

It  will  be  our  intention  in  this  chapter  to  indicate  a  few  of  these  details, 
and  by  the  use  of  pertinent  illustrations  demonstrate  how  a  chart  may  be 
made  more  valuable,  and  how,  by  the  use  of  a  word  or  two,  meaningless 

156 


THE   NURSES    CHART    IN    SURGICAL   CASES  1 57 

notations  may  be  made  more  intelligent  and  helpful.  In  the  end  it  de- 
pends upon  the  nurse's  ability  whether  her  chart  records  possess  merit 
or  demerit;  it  is  incumbent  upon  her  to  possess  the  persoaal  ability  to 
attain  these  qualifications.  We  can  only  point  out  the  way  and  hers  is  the 
responsibility  of  acquiring  the  final  perfection. 

TEMPERATURE,  PULSE,  RESPIRATION 

The  frequency  of  these  records  should  be  in  accordance  with  the  sur- 
geon's orders.     The  usual  rule  is : 

Temperature  to  be  recorded  every  three  hours.  When  unlooked-for 
complications  arise  it  should  be  recorded  every  hour.  Mere  figures  only 
impart  partial  information.  They  may  be  made  more  intelligent  if  the 
following  specifications  be  used:  "Chill,"  "Before  Bath  (B.  B.),"  "After 
Bath  (A.  B.),"  "Rectal,"  "Axilla,"  or  "After  Dressing." 

Pulse. — The  pulse  should  be  recorded  every  ten  minutes  during  the 
first  post-operative  hour;  every  fifteen  minutes  during  the  second,  third, 
and  fourth  post-operative  hours  or  until  complete  reaction  and  conscious- 
ness ensue;  every  half  hour  for  the  next  six  hours;  hourly  during  the  second 
day;  every  three  hours  thereafter.  Should  the  condition  of  the  patient  be 
unsatisfactory  frequent  records  of  the  pulse  should  be  made.  It  must  be 
remembered  that  a  pulse  of  120  requires  careful  watching;  a  pulse  of  140 
requires  anxious  watching,  and  a  pulse  of  160  that  does  not  fall  to  within 
bounds  in  four  to  six  hours  usually  foretells  impending  death.  Here  also 
mere  numbers  are  of  but  partial  value  and  alone  are  not  indicative  of 
satisfactory  conditions.  An  intermittent,  small,  weak  pulse  of  100  beats 
may  be  just  cause  for  uneasiness.  A  full,  bounding,  high-tension  pulse  of 
60  or  70  may  be  a  danger  signal.  A  nurse  should  be  on  guard  for  the 
detection  of  these  conditions  and  render  her  chart  more  intelligent  by  quali- 
fying the  mere  figures  thus: 

120,  soft,  compressible. 
140,  small,  running. 
76,  high  tension,  full. 
96,  irregular,  with  momentary  accelerations. 

By  so  doing  she  will  impart  early  warning  to  the  surgeon  whereby  he 


158 


SURGICAL   NURSING 


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THE    nurse's    chart   IN    SURGICAL   CASES 


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l60  SURGICAL   NURSING 

may  forestall  disaster  by  early  and  prompt  treatment.  Again  she  may 
prevent  his  having  any  uneasiness  if,  when  she  notes  that  at  a  certain  hour 
a  pulse  that  had  previously  been  recorded  at  78  suddenly  rose  to  100  or 
no  and  in  an  hour  or  two  subsided,  she  writes:  "Patient  annoyed  by 
workmen  in  the  building,"  or,  "Complained  of  distress  after  taking  a 
cathartic."  This  will  indicate  to  the  surgeon  that  minor  conditions  occa- 
sioned the  rise  and  that  it  was  not  due  to  possible  impending  complications. 
He  will  also  by  a  word  give  instructions  as  to  how  to  prevent  similar 
recurrences. 

The  foregoing  indicates  how  by  a  word  or  two  intelligence  and  more 
meaning  may  be  incorporated  in,  and  added  value  be  imparted  to,  a 
record.  Try  to  make  your  record  impart  the  greatest  amount  of  informa- 
tion possible,  always,  however,  avoiding  verbosity.  Discriminate  between 
essentials  and  nonessentials. 

Respiration. — The  rate  of  respiration  is  customarily  recorded  at  the 
same  time  as  the  temperature.  These  should  also  be  described  as  the  case 
may  be  by  the  use  of:  "Stertorous,"  "Shallow,"  "Labored,"  "Cheyne- 
Stokes,"  etc.  Especially  when  pulmonary  complications  exist  or  threaten 
should  one  record  specific  information  as  to  the  character  and  nature  of 
the  patient's  respiration. 

BOWEL  AND  KIDNEY  EXCRETIONS 

These  observations  are  of  utmost  importance  and  are  overlooked  or 
carelessly  recorded  by  most  nurses,  many  of  whom  are  laboring  under  the 
impression  that  a  mere  check  mark  in  the  proper  ruled  space  is  all-sufh- 
cient.  If  this  has  been  your  attitude  we  earnestly  recommend  that  in  all 
future  cases  you  record  these  alvine  discharges  more  carefully.  While 
there  is  some  satisfaction  to  a  surgeon  in  knowing  that  an  evacuation  has 
occurred,  still  the  nurse  will  assist  him  to  a  greater  extent  if  she  will  ex- 
plain thus:  "Liquid,"  "Soft,"  "Hard,"  "Light,"  "Gray,"  "Green," 
"Normal,"  "Purulent,"  "Blood,"  "Large  amount  of  mucus,"  "Very 
offensive,"  "Well  digested,"  "Undigested,"  "With  much  flatus,"  etc.  A 
word  or  two  will  impart  the  essential  and  obviate  much  needless  question- 


THE   nurse's    chart    IN    SURGICAL   CASES  l6l 

ing  or  personal  examination.     One  should  also  note  with  all  bowel  move- 
ments the  effect  that  it  produces  upon  an  abdomen  that  is  distended. 

Urine. — The  amount  of  urine  voided  must  be  accurately  measured  and 
recorded.  The  total  amount  passed  during  twenty-four  hours  should  be 
summarized  at  the  end  of  a  day's  record.  The  action  of  the  anesthetic 
agent  has  a  tendency  to  cause  a  transient  suppression  and  more  or  less 
anuria.  If  this  is  neglected  or  permitted  to  continue  undetected,  perma- 
nent suppression  followed  by  death  may  result.  If  the  failing  kidney 
action  is  discovered  early,  the  prompt  recourse  to  those  measures  calcu- 
lated to  reestablish  normal  function  will  usually  prevent  a  fatal  termina- 
tion. We  cannot  emphasize  too  strongly  the  necessity  for  careful  obser- 
vation of  kidney  secretion.  The  normal  amount  of  urine  that  is  secreted 
in  twenty-four  hours  is  from  forty-eight  to  sixty  ounces.  For  one  or  two 
days,  post-operatively,  it  may  fall  to  twenty-four  or  thirty-two  ounces  for 
each  twenty-four  hours.  When  the  amount  voided  falls  below  this  latter 
amount  the  surgeon's  early  attention  should  be  secured  and  prompt 
notification  be  given  him  at  the  least  variance  from  the  normal.  The 
record  may  be  made  more  intelligent  if  the  nurse  will  but  add  a  descriptive 
word  to  the  number  of  ounces  voided.  "Dark,"  " Offensive,"  " Scalding," 
''Frequent,"  "Difficult,"  " Catheterized,"  "Involuntary,"  etc.,  add  addi- 
tional meaning  to  the  figures  set  down.  When  securing  specimens  of 
urine  for  laboratory  examination  always  specify  whether  it  is  a  voided  or 
a  catheterized  specimen, — especially  in  gynecological  cases  or  in  operative 
work  upon  the  genitourinary  tract.  A  nurse  should  frequently  review  her 
lectures  on  urinalysis  in  order  that  she  be  constantly  familiar  with  the 
varying  characteristics  of  voided  urinary  specimens  and  thus  be  enabled  to 
detect  and  properly  interpret  them  upon  her  record. 

SLEEP— REST 

The  mere  fact  that  a  patient  lies  with  eyes  closed  does  not  warrant  the 
record  of  "sleeping."  Again,  because  a  patient  does  not  close  his  eyes 
does  not  imply  that  he  is  not  resting.  When  making  your  record  of  sleep 
be  specific  and  state,  "Normal,"  "Restless,"  "Fretful,"  "Heavy," 
"Frequent  Awakening,"  etc.,  and  thus  impart  the  essentials  that  are  of 


1 62  SURGICAL   NURSING 

some  meaning.  When  the  sleep  or  rest  has  been  unsatisfactory  the  cause 
should  be  sought  for,  and,  when  assured  of  its  discovery,  it  merits  record- 
ing so  that  when  the  surgeon  notes  it  in  his  examination  of  the  record  he 
may  be  able  to  prevent  it  happening  again  by  issuing  the  necessary  orders. 

NOURISHMENT 

Whenever  nourishment  is  administered  it  is  important  that  not  only 
its  nature  but  also  the  actual  amount  consumed  be  recorded.  If  the 
patient  is  given  a  glass  of  milk  there  should  be  noted  whether  he  consumed 
one  ounce  or  six  ounces.  If  the  taking  of  any  particulg,r  form  of  nourish- 
ment causes  discomfort  or  distress  it  must  be  recorded.  At  the  end  of 
every  twenty-four  hours  a  summarizing  of  the  total  calories  of  foodstuffs 
consumed  will  be  appreciated  by  the  surgeon.  In  addition  to  the  nourish- 
ment taken,  be  sure  to  chart  the  number  of  ounces  of  water  that  is  drunk 
by  the  patient.  The  mere  charting  of  "Soft  diet,"  "Liquids,"  or  "Light 
diet"  does  not  convey  to  the  surgeon  whether  or  not  his  patient  is  securing 
the  proper  amount  of  nourishment.  A  record  of  the  amount  of  water  that 
has  been  drunk  in  twenty-four  hours,  added  to  the  total  caloric  value  of 
the  food  that  has  been  eaten,  will  at  a  glance  indicate  to  the  surgeon  whether 
his  patient  is  receiving  the  proper  amount  of  nourishment  and  will  forestall 
the  necessity  of  making  detailed  inquiry. 

THE  WOUND 

In  "clean  cases"  there  will,  as  a  rule,  be  no  necessity  of  recording  any- 
thing pertaining  to  the  surgical  field  other  than  that  the  dressings  have 
been  regularly  inspected  by  the  nurse.  The  charting  of  "Wound  painful " 
or  "Little  pain,"  as  the  condition  may  be,  attests  to  the  nurse's  watchful- 
ness. When  the  dressings  have  become  disturbed  and  have  been  read- 
justed this  fact  should  be  noted.  In  cases  where  drainage  is  employed  the 
character  and  the  estimated  amount  of  the  discharges,  as  well  as  the  fre- 
quency with  which  the  dressings  were  renewed,  are  to  be  definitely  re- 
corded. "Dressings  changed,"  or  "Dressings  soiled,"  do  not  mean 
much.  How  often  were  they  changed  and  what  was  the  nature  of  the 
discharge — blood,  pus,  serum,  fluid — and  what  was  the  amount?  These 
are  pertinent  observations.     In  changing  the  dressings  when  there  is 


THE   nurse's    chart    IN    SURGICAL   CASES  163 

drainage  in  the  wound,  it  is  well  to  note  from  time  to  time  the  condition  of 
the  drainage  material  and  also  that  of  the  sutures  that  are  in  place.  Never 
fail  to  promptly  record  the  very  first  indication  of  commencing  irritation 
or  inflammation  of  the  surrounding  skin  due  to  constant  contact  with 
wound  discharges.  It  is  equally  important  that  record  be  made  when  the 
drainage  material  was  removed.  ''Dressing  done,"  means  nothing.  How 
and  what  was  done  is  important  and  should  be  observed  every  time  the 
dressings  are  removed  and  the  wound  exposed  to  the  air. 

In  "clean  cases"  record  the  day  when  the  stitches  are  removed  and 
note  the  condition  of  the  wound  thus:  "Union  complete,"  "Union  by 
second  intention,"  "Wound  broken  down  in  center,"  etc. 

MISCELLANEOUS  DETAILS 

Under  this  heading  we  propose  to  indicate  but  briefly  several  ap- 
parently minor  details  which  are,  however,  of  greater  or  less  importance 
in  every  surgical  case  and  which  a  surgical  nurse  will  be  called  upon  at 
intervals  to  include  in  her  chart,  or  which  will  serve  to  enable  her  to  add 
increased  value  to  her  chart. 

Days. — Always  at  the  beginning  of  a  new  record-sheet  note  the  day 
that  the  sheet  covers  following  the  operation,  as,  Fifth  Day.  It  facilitates 
the  reading  of  a  chart  if  one  uses  black  ink  for  the  records  made  between 
7  a.m.  and  7  p.m.,  and  red  ink  for  the  hours  between  7  p.m.  and  7  a.m. 

The  Operation. — Have  your  chart  record  the  day  and  hour  your  patient 
was  sent  to  the  operating  table  together  with  the  following  details  of  the 
operation :  Names  of  the  surgeon  and  his  assistants  and  the  anesthetist ; 
nurses  present;  time  of  operation;  duration  of  operation;  anesthetic  agent 
employed;  nature  of  operation  and  what  organs  or  tissues,  if  any,  were 
removed;  suture  material  used  in  closing  the  wound  and,  if  drainage  is 
used,  state  its  nature,  amount,  and  how  used;  what  disposal  was  made  of 
the  specimens;  condition  of  patient  during  operation;  pulse  before  and  at 
the  completion  of  the  operation;  pulse  and  condition  of  the  patient  when 
returned  to  bed;  stimulation  that  was  administered,  if  any. 

Medication. — Whenever  any  medicine  is  given,  always  state  specifically 
the  time,  how,  and  what  was  given.  Never  permit  your  chart  to  contain 
the  phrase,  "Medicine  given  as  ordered." 


164  SURGICAL   NURSING 

These  are  all  little  things,  you  say,  but  it  is  these  very  little  things  and 
the  attention  that  a  nurse  directs  to  them  that  tend  to  rate  you  as  a  com- 
petent, observing,  and  careful  nurse  and  cause  your  services  to  be  sought 
by  surgeons.  There  is  nothing  more  annoying  than  to  pick  up  a  meaning- 
less chart  and  be  compelled  to  ask  numerous  questions  in  order  that  it 
may  be  properly  interpreted.  There  is  also  nothing  so  satisfying  as  to 
know  that  one's  patient  is  under  the  care  of  a  watchful  nurse.  It  is  yours 
to  choose  whether  you  will  be  classed  as  an  excellent  or  poor  surgical 
nurse,  and  yours  also  to  attain  such  approval  by  the  care  and  studied 
thought  with  which  you  write  your  charts. 


CHAPTER  XIII 

FORMULiE,  ETC. 
MUSTARD  PLASTER 

For  an  adult,  use  i  part  of  mustard  to  4  or  6  parts  of  wheat  flour;  for  a  child,  i  part  of  mustard 
to  8  parts  of  flour.  Mix  the  dry  flour  and  mustard,  wet  with  lukewarm  water,  and  spread  evenly 
over  half  a  piece  of  muslin,  leaving  a  wide  margin.  Fold  the  other  half  of  the  muslin  over  the  paste 
and  bring  the  margins  over  the  sides  to  retain  the  mixture.  The  white  of  an  egg  added  to  the  paste 
will  reduce  the  danger  of  blistering. 

FLAXSEED  POULTICE 

Linseed  meal ^^  cup 

Boiling  water i  cup 

Sprinkle  the  linseed  meal  into  the  boiling  water  and  stir  constantly  to  prevent  lumps.  When 
thick  enough  to  drop,  not  run,  from  the  spoon,  remove  from  the  fire  and  beat  vigorously  until  sufficient 
air  has  been  incorporated  into  the  mixture  to  make  it  light.  Spread  not  less  than  one-half  inch 
thick  on  muslin,  leaving  an  ample  margin.  Cover  with  a  piece  of  gauze  and  fold  the  margin  of  the 
muslin  over  the  poultice  so  that  none  of  the  mixture  can  escape.  Carry  to  the  bedside  in  a  heated 
dish  or  rolled  in  a  hot  towel. 

MUSTARD  POULTICE 

For  an  adult,  a  mustard  poultice  should  contain  i  part  of  ground  mustard  to  8  parts  of  flaxseed 
meal;  for  a  child,  i  part  of  mustard  to  12  parts  of  flaxseed.  Prepare  a  flaxseed  poultice,  and  stir  in 
the  dry  mustard  after  removing  from  the  fire.  Spread  evenly  on  half  a  piece  of  muslin  and  completely 
cover  with  the  other  half. 

TINCTURE  OF  lODIN 

Tincture  of  iodin  is  often  used  as  a  counterirritant.  Apply  with  a  pledget  of  cotton  or  a  gauze 
sponge  on  an  applicator  and  allow  it  to  dry.  As  the  tincture  spreads  freely,  the  site  may  be  sur- 
rounded with  cold  cream  to  limit  the  area  of  application.  Let  dry  before  making  a  second  application 
if  such  is  required.     One  application  daily  is  usually  all  that  is  prescribed. 

TURPENTINE  STUPES 

Mix  olive  oil  and  turpentine  (for  adults,  3  or  4  parts  of  oil  to  i  of  turpentine;  for  children,  8  to  10 
parts  of  oil  to  i  of  turpentine) ,  apply  to  the  part,  and  cover  with  a  hot  fomentation.  Or,  add  one 
teaspoon  of  turpentine  to  a  pint  of  boiling  water,  mix  thorough!}',  put  into  it  the  flannel,  and  stir 
until  the  flannel  is  thoroughly  saturated.     Wring  out  and  apply. 

CHEMICAL  DISINFECTANTS  AND  ANTISEPTICS 

ALCOHOL 

70  per  cent,  for  skin  disinfection. 

70  per  cent,  to  95  per  cent,  for  surgical  instruments,  needles,  and  dishes  which  are  free  from 
albuminous  matter. 

i6s 


1 66  SURGICAL   NURSING 

BICHLORID    or   MERCURY 

Bichlorid  of  mercury  is  limited  in  its  use  as  a  disinfectant  because  it  is  precipitated  in  the  pres- 
ence of  albuminous  matter  and  corrodes  metals.  For  these  reasons  it  is  not  adapted  to  the  disin- 
fection of  feces  and  sputum  nor  the  sterilization  of  instruments.     It  is  used  in  the  following  strengths: 

I  in  looo  for  clothing,  bedding,  linen,  handkerchiefs. 

I  in  looo  for  floors,  furniture,  walls. 

I  in  looo  for  skin  disinfection. 

I  in  3000  to  I  in  1000  for  the  hands. 

Standard  Bichlorid  of  Mercury  Solution,  i  in  1000 

Water  (which  has  been  boiled) i  pint 

Bichlorid  of  mercury 7.3  grains 

Common  salt 14.6  grains 

I  in  2000  Bichlorid  of  Mercury  Solution 
Add  I  part  of  the  standard  solution  to  an  equal  part  of  boiled  water. 

I  in  3000  Bichlorid  of  Mercury  Sohition 
Add  I  part  of  the  standard  solution  to  2  parts  of  boiled  water. 

I  in  5000  Bichlorid  of  Mercury  Solution 
Add  I  part  of  the  standard  solution  to  4  parts  of  boiled  water. 

BORIC   ACID 

Saturated  solution  diluted  one-half  for  an  infant's  eyes  and  mouth. 
Saturated  solution  for  all  other  purposes. 

CARBOLIC   ACID 

Carbolic  acid  has  a  wide  range  of  use  as  a  germicide  because  it  does  not  actively  coagulate  albumin 
nor  destroy  colors,  wood,  metal,  or  fabrics  in  the  usual  strengths  employed.  For  disinfection  in 
smallpox,  scarlet  fever,  measles,  and  syphilis  it  is  said  to  be  unreliable.  With  these  exceptions  it 
can  be  depended  upon  for  use  in  the  following  strengths: 

5  per  cent,  for  dishes,  utensils,  floors,  woodwork,  clothing,  bedding,  feces,  urine,  and  vomitus. 

3  per  cent,  to  5  per  cent,  for  the  hands. 

3  Per  Cent.  Carbolic  Acid  Solution 

Water i  quart 

Carbolic  acid i  ounce  (2  tablespoons) 

5  Per  Cent,  (i  iti  20)  Carbolic  Acid  Solution 

Water i  quart 

Carbolic  acid 1}^  ounces  (3  tablespoons) 

To  prevent  burning,  carbolic  acid  solution  should  be  thoroughly  mixed  before  using.  Alcohol 
is  an  antidote  for  carbolic  acid  burns. 

CHLORINATED  LIME 

Chlorinated  lime  can  be  used  either  in  solution  or,  for  excreta,  as  a  dry  powder. 
3  per  cent,  for  feces,  urine,  sputum,  and  bath  water. 

3  Per  Cent.  Chlorinated  Lime  Solution 

Chlorinated  lime 3  ounces 

Water i  gaUon 


FORMULA,   ETC.  167 

FORMALIN 

Formalin  is  a  deodorant  as  well  as  a  disinfectant  and  docs  not  lose  its  disinfecting  properties  in 
the  presence  of  albuminous  matter.  Hot  formalin  injures  iron  and  steel  but  it  is  not  injurious  to 
brass,  copper,  nickel,  and  other  metals.     It  is  not  destructive  to  fabrics  and  does  not  affect  colors. 

10  per  cent,  for  clothing,  bedding,  linen,  handkerchiefs,  dishes,  utensils. 

10  per  cent,  for  feces,  urine,  sputum,  vomitus. 

10  Per  Cent.  Formalin  Solution 

Formalin 13  ounces 

Water i  gallon 


Lysol  is  a  more  powerful  germicide  than  carbolic  acid  and  in  the  strengths  used  is  nonirritating. 

2  per  cent,  for  sputum,  and  let  stand  for  one  hour. 

2  per  cent,  for  utensils,  woodwork,  dishes,  and  rubber  articles. 

NORMAL   SALT    SOLUTION 

Common  salt 46  grains 

(slightly  less  than  a  level  teaspoon) 
Water i  pint 

METHODS  OF  DISINFECTION 

TO  DISINFECT  Vv'ATER 

Boil  thirty  minutes.  Water  used  for  bathing  in  an  infectious  or  contagious  disease  may  be  dis- 
infected by  milk  of  lime  (containing  i  part  of  freshly  slaked  lime  to  4  parts  of  water) .  Add  an  equal 
amount  of  freshly  prepared  milk  of  lime  to  the  water  to  be  disinfected  and  let  stand  for  not  less  than 
two  hours. 

TO  DISINFECT  T.ABLEWARE  AND  UTENSILS 

Boil  thirty  minutes,  or,  if  preferred,  soak  in  5  per  cent,  carbolic  acid  solution,  10  per  cent,  formalin, 
or  2  per  cent,  lysol. 

TO   DISINFECT   CLOTHING 

Immerse  in  carbolic  acid,  5  per  cent.,  or  formalin,  10  per  cent,  for  two  hours,  or  boil  for  from  one- 
half  to  one  hour. 

TO    STERILIZE    TOWELS,    GAUZE,    ETC. 

Wrap  loosely  in  small  packages  and  boil  thirty  minutes.  To  dry,  after  boiling,  wrap  packages  in 
several  thicknesses  of  paper  and  bake  in  a  slow  oven.  Small  pieces  of  clean  gauze  (one  thickness) 
may  be  sterilized  by  moistening  and  ironing  with  a  scorching  hot  flatiron. 

TO    DISINFECT    SPUTUM 

Receive  in  paper  sputum  cups  and  burn  immediately,  or  add  formalin,  10  per  cent.,  chlorinated 
lime,  3  per  cent.,  or  lysol,  2  per  cent.,  and  allow  to  stand  for  one  hour. 

TO    DISINFECT    FECES 

Incorporate  an  equal  quantity  of  a  disinfecting  solution  and  allow  to  stand  for  from  one  to  two 
hours,  according  to  the  disinfectant  used.  The  disinfectant  and  feces  should  be  thoroughly  mixed. 
Use  one  of  the  following  solutions:  10  per  cent,  formalin  for  one  hour,  5  per  cent,  carbolic  acid  for 
from  one  to  two  hours,  3  per  cent,  chlorinated  lime  for  at  least  two  hours. 


1 68  SURGICAL   NURSING 

TEMPERATURES  OF  WATER  FOR  BATHS,  APPLICATIONS,  DOUCHES,  AND  ENEMAS 

As  a  rule,  determine  all  temperatures  by  a  bath  thermometer  and  not  by  the  hand. 

Very  cold 32°  to    55°F. 

Cold ■ 55°  to    65°F. 

,   Cool 65°  to    8o°F. 

Tepid 80°  to    92°F. 

Neutral 92°  to    95°F. 

Warm ' 92°  to    98°F. 

Hot 98°  to  io4°F. 

Very  hot . .  .  . ' 104°  and  above 

ENEMATA 
Classification  of  Enemata. — 

Anthelmintic:  given  to  destroy  worms. 
Antiseptic:  given  to  destroy  worms. 

Astringent:  given  to  contract  the  tissue  and  superficial  capillaries  in  cases  of  hemorrhage  and 
forms  of  diarrhea. 

Carminative:  given  to  relieve  flatulence. 

Emollient:  given  to  soothe  irritation  of  the  mucous  membrane  of  the  intestines. 

Nutritive:  given  to  afford  nourishment. 

Purgative:  given  to  increase  peristalsis  and  wash  the  intestines. 

Sedative:  given  as  a  sedative,  general  and  local. 

Stimulating:  given  for  general  stimulation. 

Saline:  given  to  replenish  body  fluids  and  for  stimulation. 

STIMULATING  ENEMA 

1 .  Saline §  viij 

Coffee 5  viij 

Whiskey 5  ss 

Temperature io5°F. 

2.  Normal  saline. O  j 

Temperature io5°F. 

3.  Whiskey 5  J 

Black  coffee B  iv 

Liquid  peptonoids §  ij 

Normal  saline,  ad O  j 

Temperature io5°F. 

GLYCERIN  ENEMA 

Glycerin §  ij 

Water 5  iv 

SALTS  AND  GLYCERIN  ENEMA 

Magnesium  sulphate 5    ij 

Glycerin 5   iv 

Water,  ad O  j 

OIL  ENEMA 

I.  Warm  olive  oil 5   vj 

Followed  by  soapsuds  and  glycerin  enema  in  one  hour. 


FORMULA,  ETC.  1 69 

2.  Castor  oil 5  ij 

Sweet  oil 5  ij 

Glycerin 5  i J 

Water,  q.  s.  ad O  j 

OIL  AND  TURPENTINE  ENEMA 

To  oil  enema  add  turpentine 5  ss 

CARMINATIVE  ENEMA 

1.  Milk  of  asafetida g  viij 

2.  Turpentine.  . §  ss 

Water O  j 

Milk B  iv 

Molasses 5  iv 

NUTRITIVE  ENEMA 

1.  Egg I 

Beef  juice 5  iJ 

Table  salt : gr.  xv 

Peptonized  milk 5  vj 

2.  Liquid  peptonoids 5  ij 

Normal  saline 5  iJ 

3-  Egg I 

Peptonized  milk §  vj 

The  Method  of  Administering  Nutritive  or  Stimulating  Enemata. — Prepare  the  fluid  and  heal  to 
95°F.  Place  the  patient  on  the  left  side  with  the  knees  flexed.  Permit  the  fluid  to  flow  through  the 
tube  to  expel  the  air  and  then  make  pressure  close  to  the  point  until  ready  to  introduce  it.  Lubri- 
cate the  catheter  with  vaselin  or  oil  and  insert  gently  six  or  eight  inches.  Do  not  slip  the  tube  back- 
ward or  forward  as  it  increases  peristalsis  and  induces  the  patient  to  expel  the  fluid  which  should  be 
retained.  Press  the  tube  sufficiently  to  allow  the  fluid  to  run  very  slowly  and  occasionall)'  make 
intermittent  stoppage  until  it  has  been  all  given.  Upon  withdrawing  the  tube  make  digital  pressure 
with  a  soft  cloth  against  the  anus  for  a  minute  or  two.  Give  a  rectal  irrigation  before  a  stimulating 
or  nutritive  enema  unless  otherwise  ordered. 

SALINE  ENEMA 

Epsom  salt  (magnesium  sulphate) 2  ounces 

Water i  quart 

MOLASSES  ENEMA 

Molasses 8  ounces 

Water i  quart 

TURPENTINE  ENEMA 

Turpentine i  dram 

Epsom  salt 2  drams 

Glycerin 4  drams 

Warm  water 4  ounces 

Or 

Turpentine 20  drops 

Soapsuds I  pint 


1 70  SURGICAL   NURSING 

FLAXSEED  ENEMA 

Flaxseed  meal 8  ounces 

Water i  pint 

Tie  flaxseed  in  cheesecloth,  boil  for  one  hour,  and  strain. 

SEDATIVE   (starch)    ENEMA 

'    Starch i  ounce 

Cold  water Enough  to  soften 

Boiling  water ....  Sufficient  to  make  the  consistence  of  thick  cream  when  boiled. 
Asafetida  and  laudanum  may  be  added  to  this  enema  as  prescribed. 

SOAPSUDS  ENEMA 

Warm  enema,  water  at  98°  to  100° i  to  3  pints 

Hot  enema,  water  105°  to  110° i  to  3  pints 

Cold  enema,  water  at  70°  to  80° i  to  3  pints 

Retain  for  from  5  to  15  minutes. 


CHAPTER  XIV 
PREPARATION  OF  SURGICAL  MATERIALS 

Catgut  (The  Willard  Bartlett  Method).— The  gut  is  cut  into  desired 
lengths  and  made  into  coils  which  are  hung  on  a  thread,  so  that  they  can 
be  conveniently  handled.  They  are  then  placed  upon  asbestos  in  a  hot- 
air  chamber  and  the  temperature  is  gradually  raised  during  an  hour  to 
i8o°F.,  during  the  next  hour  it  is  raised  to  2  20°F.  and  continued  at  this 
temperature  for  thirty  minutes.  The  gut  is  now  transferred  to  an  asbestos- 
lined  kettle  and  placed  in  liquid  alboline  until  it  is  clear  in  the  sense  that 
microscopic  sections  are  clear;  this  requires  twelve  hours.  The  kettle  is 
then  placed  upon  a  sand  bath,  and  by  gradually  raising  the  temperature 
through  a  period  of  two  hours  the  maximum  temperature  of  320°F. 
is  reached,  at  which  point  it  is  kept.  Brittleness  results  from  raising  the 
temperature  too  rapidly  and  exceeding  the  maximum  temperature. 
The  gut  is  finally  stored  in  a  solution  of  i  part  iodin  crystals  in  loo  parts 
of  Columbian  spirit.  To  get  rid  of  the  excess  of  oil  the  gut  is  either 
allowed  to  drip  or  is  rinsed  in  the  storing  solution. 

Catgut  in  Glass  Tubes. — Boil  for  five  minutes  before  using  or  place 
in  I  in  500  corrosive  sublimate  for  thirty  minutes. 

Kangaroo  Tendon  in  Glass  Tubes.— Never  boil.  Keep  in  i  in  500 
corrosive  sublimate  solution. 

Horsehair. — To  prepare  horsehair  for  ligatures : 

1.  Wash  thoroughly  with  soap  and  water. 

2.  Boil  twenty  minutes  in  4  per  cent,  sodium  bicarbonate  solution. 

3.  Preserve  in  alcohol,  70  per  cent. 

Silk  Plaited  or  Twisted,  Black  Linen,  and  Pagenstechei's  Linen. — 

Wind  on  glass  cylinders  and  boil  vigorously   (small  sizes  for   twenty 

minutes,  large  sizes  for  thirty  minutes)  previous  to  operation,  or,  after 

winding  silk  on  cylinders,  place  cylinders  in  glass  tubes,  plug  tubes  with 

171 


172 


SURGICAL   NURSING 
MAKING  GAUZE  DRESSINGS 


Y 


Fji,.  lou. — Cutting  Layers  prom  the  Bolt  of        Fig.  iio. — Trimming  Off  the  Folded  Edge. 
Gauze. 


Fig.  III. — Cutting  the  Gauze  Squares  IN  Half.      Fig.  112. — Placing  the  Layers  in  One  Pile. 


\ 


> 


1 


Fig.  113. — ^IvIfting  a  Single  Layer.  Fig.  114. — Folding  Top  Layer  to  One  Half. 


.*^» 


Fig.  115. — Folding  Again  into  a  Narrow  Strip.     Fig.  116. — Folding  Over  One  Third  of  Strip. 


PREPARATION    OF    SURGICAL    MATERIALS 


173 


Fig.  117. — Folding  Over  Opposite  Third. 


Fig.    118. — Strip   Folded,    Ready    to    Turn 

Inside  Out. 


Fig.    119. — Fingers    Separating    One  Layer       Fig.  120. — Turning  Inside  Out,  First  Time. 
OF  Gauze  to  Turn  Inside  Out. 


r'' 


Fig.  121. — Dressing  Ready  eor  Second  Turn. 


Fig.  122. — Fingers   under   Two  Layers   to 
Turn  Inside  Out  Again. 


•V 


»^> 


Fig.  123. — Turning  Inside  Out. 


Fig.    124. — Dressing    Coaiplkted    wttu    Raw- 
Edges  Concealed. 


174 


SURGICAL   NURSING 


cotton,  and  sterilize  with  live  steam  at  fifteen  pounds  pressure  on  two 
successive  days. 

Silkworm  Gut. — 

'I.  Cut  off  rough  ends  of  the  commercial  silkworm-gut  fibers. 

2.  Boil  vigorously  for  thirty  minutes  in  clean  water. 

3.  Preserve  in  alcohol,  70  per  cent. 


Fig.  125. — Cutting  and  Packing  Gauze  Dressings. 


PREPARATION    OF    SURGICAL   MATERIALS 


175 


Fig.  126. — Cutting  and  Packing  Gauze  Dressings  (Continued). 


Rubber  Tubing  and  Rubber  Dam. — 

1.  Cut  in  lengths. 

2.  Blow  out  dust. 

3.  Boil  in  a  4  per  cent,  solution  of  sodium  bicarbonate  for  twenty 
minutes. 

4.  Scrub  and  wash  thoroughly  with  green  soap. 

5.  Soak  in  corrosive  sublimate,  i  in  500,  for  twelve  hours. 

6.  Boil  again  for  twenty  minutes  and  place  in  5  per  cent,  carbolic 
acid  solution. 

Rubber  Tissue. — 

1.  Wash  and  soak  in  green  soap  and  cold  water. 

2.  Rinse  thoroughly  with  sterile  water. 

3.  Immerse  in  corrosive  sublimate,  i  in  500,  for  twelve  hours. 

4.  Preserve  in  sterile  normal  salt  solution. 


176  SURGICAL   NURSING 

Rubber  Gloves. — 

1.  Wash  gloves  with  cold  water. 

2.  Wash  with  green  soap  and  hot  water,  rinse  thoroughly,  and  boil  for 
five  minutes. 

3.  Dry,  mend,  powder,  and  sort. 

4.  Sterilize  in  double  covers  in  which  gloves  are  laid  fiat  and  separated 
by  the  cover,  for  half  an  hour  at  twelve  pounds  pressure. 

After  gloves  are  mended,  sort,  roll  each  pair  in  gauze  (marked),  boil  for 
twenty  minutes  in  4  per  cent,  sodium  bicarbonate  solution.  Gloves  are 
then  taken  out,  placed  on  sterile  table,  and  laid  upon  double  thickness 
of  sterile  towels,  one  pair  at  a  time ;  then  outer  surfaces  are  partly  dried 
with  towels.  Gloves  turned  by  edge  of  cuff  and  inner  surface,  dried, 
powdered  on  both  sides,  rolled  in  sterile  gauze,  and  folded  in  double  thick- 
ness of  sterile  towels.  The  nurse,  before  beginning  to  take  gloves  from 
sterilizer,  will  scrub,  wear  gloves,  and  take  all  precaution  that  the  process 
be  absolutely  sterile  throughout. 

Towels,  Sheets,  Gowns,  Etc.— 

1.  Remove  blood,  pus,  etc.,  by  soaking  in  cold  water  to  which  may  be 
added  a  little  ammonia. 

2.  Rinse  thoroughly. 

3.  Launder. 

4.  On  return,  mend,  fold,  wrap  in  package  or  bag,  pinning  snugly. 
Place  in  steam  sterilizer  for  half  an  hour  at  fifteen  pounds  pressure;  dry 
for  fifteen  minutes.  New  towels,  sheets,  etc.,  should  be  boiled  before 
sterilizing. 

Plain  Gauze  Pads,  Packing,  and  Dressings. — 

Large  square  laparotomy  sponges,  9  thicknesses,  15  by  15  when  finished. 
Medium  laparotomy,  sponges,  9  thicknesses,  15  by  6  when  finished. 
Small  square  cut  gauze,  9  by  12. 
Small  long  cut  gauze,  9  by  22. 
Scrub  cut  gauze,  14  by  18. 
Vaginal  cut  gauze,  7  by  9. 

Sponges  not  sewed  are  so  folded  that  all  raw  edges  will  be  held  securely 
inside. 


PREPARATION    OP    SURGICAL    MATERIALS  1 77 

All  gauze  sponges  are  sterilized  by  steam  for  half  an  hour  at  fifteen 
pounds  pressure,  and  the  process  repeated  at  twenty-four-hour  intervals 
for  three  days. 

STRIPS 

Corrosive  Cotton. — Cut  absorbent  cotton  in  two-inch  cubes,  place  in  a 
bag,  tie  loosely,  soak  in  corrosive  sublimate,  i  in  loo,  for  twenty-four  hours; 
dry  in  a  sterilizer,  shaking  from  time  to  time. 

Tampons. — Cut  lamb's  wool  in  convenient  sizes,  two  by  four  inches  and 
eight  by  ten  inches.  Tie  a  strong  string  around  the  middle  of  the  tampon 
to  facilitate  its  withdrawal.  The  ends  of  this  string  should  be  knotted 
together. 

Cut  strips  of  absorbent  cotton  two  inches  thick  by  four  inches  long. 
Double  these  strips  and  tie  with  strong  thread,  the  ends  to  be  six  inches 
long  and  knotted. 

Iodoform  Foimula. — 

Normal  salt  solution 6  ounces 

Green  soap 1,^  dram 

Carbolic  acid,  95  per  cent : .      3  drops 

Heat  the  above  mixture  lukewarm  and  add  two  drams  of  iodoform 
powder;  dissolve  and  mix  thoroughly;  then  rub  well  into  three  yards^of 
gauze  which  has  been  previously  sterilized  for  half  an  hour  at  fifteen  pounds 
pressure.  Before  making  this  gauze,  the  nurse  should  scrub  up,  put  on 
sterile  gown,  cap,  mask,  and  gloves  and  have  everything  used  in  the  proc- 
ess absolutely  sterile. 

Dakin's  Solution. — 

Dry  carbonate  of  soda 140  grams 

Sterile  water 10  liters 

Chloride  of  lime 200  grams 

Shake  well  and  let  stand  for  a  half  hour.     Siphon  off  the  water. 

Then  add^ — 

Boric  acid 40  grams 

This  solution  should  be  neutral  in  reaction  and  is  in  proper  strength  for 
use.     It  should  be  made  fresh  every  three  days. 


CHAPTER  XV 
THE  SURGEON'S  HOSPITAL  KIT 

While  better  service  and  greater  conveniences  are  naturally  secured  in 
a  hospital  when  surgical  work  is  to  be  undertaken,  yet  occasions  present 
themselves  when,  for  one  reason  or  another,  it  is  wholly  out  of  the  question 
to  remove  the  patient  to  the  hospital.  In  such  an  event,  it  becomes  neces- 
sary to  perform  the  operation  in  the  patient's  home,  where  an  operating 
room  must  be  prepared. 

The  problem  of  providing  sterile  supplies,  such  as  sutures,  sponges, 
gowns,  and  all  other  necessary  material,  has  been  greatly  simplified  by  the 
hospital  kit.  This  kit  is  prepared  at  the  hospital  and  its  contents  meet 
all  the  requirements  of  the  nurses  and  surgeon  who  conduct  the  operation. 
The  supplies  that  of  necessity  must  be  sterile  are  sterilized  in  the  hospital 
and  are  contained  in  wrappers  or  covers  which  prevent  their  contamination. 
The  entire  kit  is  sent  out  with  the  nurse  or  it  may  accompany  the  surgeon. 
A  fee  of  from  five  to  ten  dollars  is  customarily  charged  by  the  hospital  for 
the  preparation  and  loan  of  these  supplies. 

The  accompanying  illustrations  are  of  what  is  known  as  a  full,  or 
complete,  kit.  Its  contents  are  calculated  to  be  sufficient  to  supply 
any  operative  need.  A  special  kit  contains  only  the  required  supplies  for 
a  special  or  given  operation.  The  only  difference  is  that  the  amount  or 
number  of  the  individual  supplies  is  less.  For  example,  a  full  kit  will 
contain  four  or  six  large  sterile  sheets.  This  number  of  sheets  is  not 
required  in  an  appendectomy;  consequently  in  a  kit  that  has  been  pre- 
pared for  an  appendectomy  there  will  be  but  three  sheets.  This  deter- 
mination of  the  number  of  supplies  is  observed  in  selecting  the  entire  con- 
tents. It  is  only  when  the  nature  of  the  operation  is  unknown  that  the 
full  kit  is  sent  out. 

The  container  of  these  goods  may  be  of  any  nature  or  style.     However, 

a  telescope  of  heavy  fiber,  as  shown  in  the  illustrations,  will  be  found  most 

178 


THE.  SURGEON  S    HOSPITAL    KIT 


179 


Fig.  127.- — The  Surgeon's  Hospital  Kit. 

The  kit  is  ready  to  send  anywhere,  and  with  its  contents  an  aseptic  operation  may  be  performed 

without  fear  that  the  supplies  are  not  sterile. 


SUriU 


Fig.  128. — Chemicals  and  Solutions  Contained  in  Sterile  Kit. 
lodin-benzin,    alcohol,    green    soap,    sterile    vaselin,    bichlorid  tablets,  Harrington's  solution, 
carbolic  acid,  tincture  of  iodin,  oil  of  cloves,  formaldehj'd,  collodion. 


l8o  SURGICAL   NURSING 

serviceable  and  convenient  and  will  withstand  the  hard  usage  incidental  to 
sending  by  express  or  otherwise.  The  style  of  the  telescope  makes  it 
adaptable  to  the  space  required  by  the  contents  of  the  various  kits.  The 
total  Weight  of  a  full  kit  approximates  seventy  pounds. 

CONTENTS 

The  contents  of  a  full  kit  consist  of  the  following  articles,  which  are 
firmly  and  snugly  packed  in  the  telescope.  Those  marked  "S"  contain 
sterile  supplies.  The  following  Ust  is  numbered  to  correspond  with  the 
numbered  articles  in  the  engraving  (Fig.  129). 

1.  Sterile  granite  basins,  4,  "S." 

2.  Packages  of  catgut,  i  dozen  each,  "S": 

0  Plain  I  Chromic 

1  Plain  2  Chromic 

2  Plain  3  Chromic 

3  Plain  4  Chromic 

3.  Ether,  4  ounces,  5  packages. 

3.  Chloroform,  4  ounces,  2  packages. 

4.  Adhesive  tapes. 

5.  Stack  of  sheets,  6,  drapes,  "S." 

6.  Stack  of  towels,  2  dozen,  "S." 

7.  Alcohol,  70  per  cent.,  i  pint. 

8.  Green  or  liquid  soap,  i  pint. 

9.  lodin-benzin,  i  in  100,  i  pint. 

10.  Tincture  of  iodin,  8  ounces. 

11.  Bichlorid  of  mercury  tablets,  100. 

12.  Collodion,  4  ounces. 

13.  Harrington's  solution,  4  ounces. 

15.  Formaldehyd  for  preserving  specimens. 

16.  Oil  of  cloves,  4  ounces. 

17.  Assortment  of  rubber  drainage  tubes. 

18.  Carbolic  acid. 

19.  Sterile  vaselin,  2  ounces. 

20.  Rubber  and  glass  catheters. 

21.  Glass  irrigating  tips,  2. 

22.  Tube,  I,  containing  6  yards  iodoform  packing. 

23.  Assorted  gauze  bandages,  J-'2  dozen. 

24.  Gauze  dressings,  5  packages;  sponges,  8  packages;  gauze  packing,  5  yards,  "S." 

25.  Walling-off  packs,  3  packages,  4  each,  "S." 

26.  Silk,  linen,  and  silkworm-gut  sutures. 

27.  Razor. 

28.  Surgeon's  and  nurses'  gowns,  4,  "  S." 

29.  Salt  blocks,  "S." 

30.  Gloves,  6  pairs,  "S." 

31.  Surgeon's  suit. 

33.  Applicators,  6,  "S." 

34.  Packing-off  strips,  2  packages,  "S." 

35.  Talcum  powder  for  hands,'j."S." 

36.  Extra  gloves. 

37.  Safety  pins. 


THE    SURGEON  S    HOSPITAL   KIT 


l8l 


Articles  not  shown  in  engraving: 

Scrub  brushes,  6;  orange  sticks. 

Anesthetic  masks. 

Kelly  pad,  i. 

Rubber  syringe  bag,  i. 


Fig.  129. — Contents  of  a  Full  Kit. 
Unopened  packages,  showing  what  is  contained  in  the  kit.     These  supplies  are  placed  unopened 
upon  the  supply  table  and  are  so  opened  by  the  unscrubbed  nurse  that  their  contents  can  be  removed 
without  contamination  and  placed  upon  the  sterile  table. 


USE  OF  THE  KIT 

Every  package  and  every  bottle  is  properly  labeled  so  that  identifica- 
tion is  not  difficult.  The  kit  is  customarily  unpacked  in  the  room  in  which 
the  operation  is  to  be  performed.  After  unstrapping  and  removing  the 
upper  part  of  the  telescope,  the  contents  are  arranged  upon  the  table  that 
is  to  be  used  for  unopened  supplies.  The  rule  governing  the  opening  of 
packages  containing  sterile  goods  is  to  be  observed  when  immediate  prepa- 
ration for  the  operation  is  begun. 

The  kit  is  returned  to  the  hospital  promptly  after  the  operation  is  com- 


l82 


SURGICAL   NURSING 


pleted.  Sheets  and  towels  that  have  become  soiled  with  blood  should  be 
rinsed  in  cold  water  to  remove  the  blood  stains  and  wrung  out  before 
repacking  in  the  kit.  All  unused  solutions  should  be  returned  to  their 
original  containers. 


Fig.  130. — Packages  or  Sterile  Goods,  Showing  How  the  Contents  are  Wrapped  in  Outer 
Envelopes  or  Containers  of  Heavy  Cotton  Flannel. 


If  the  operation  is  one  in  which  pus  has  been  encountered,  a  note  is 
placed  on  top  of  the  repacked  contents  stating  that  the  kit  has  been  used  in 
a  pus  case.  This  is  for  the  information  of  the  surgical  nursing  staff  of  the 
hospital  and  directs  their  course  in  the  unpacking  and  making  up  of  a  new 
kit. 


CHAPTER  XVI 
THE  PLASTER-OF-PARIS  SPLINT 

Numerous  artificial  contrivances  have  been  devised  to  maintain  in 
apposition  fractures  of  long  bones  and  to  immobilize  injured  or  diseased 
joints.  Some  of  these  devices  have  met  with  a  kindly  reception  while 
others  have  been  found  so  cumbersome  or  so  complex  mechanically  that 
their  value  is  lost.  Frequently  a  prohibitory  cost  has  rendered  a  contri- 
vance impracticable  for  the  average  case. 

While  these  mechanical  contrivances  may  be  found  in  the  larger  hos- 
pitals and  sanitariums,  their  use  is  not  common  in  general  practice.  The 
nurse  called  to  serve  in  any  case  where  immobilization  of  a  joint  or  a  bone 
is  indicated  will,  in  the  majority  of  instances,  hear  the  physician  or  surgeon 
order  a  plaster-of-Paris  splint  for  the  purpose  of  providing  mechanical 
support.  Very  frequently  the  nurse  will  be  called  upon  to  perform  the 
preliminary  details  of  making  and  applying  such  a  splint,  and  it  is  the 
object  of  this  article  to  acquaint  her  with  an  accepted  method. 

There  are  two  grades  of  plaster-of-Paris  on  the  market.  One  is  the 
ordinary  commercial  plaster-of-Paris,  the  other,  a  finer  grade  known  as 
dental  plaster.  It  may  be  difficult  to  secure  dental  plaster  in  all  localities; 
but  if  it  is  obtainable,  it  is  to  be  preferred  for  two  reasons :  its  freedom  from 
gritty  and  foreign  substances,  and  its  property  of  rapid  hardening  as  well 
as  its  lessened  tendency  to  crumble.  If  dental  plaster  is  unobtainable  the 
commercial  plaster  will  serve  the  purpose  with  reasonable  satisfaction.  Its 
slow  hardening  may  be  overcome  in  some  degree  by  adding  salt  to  the 
water  used  in  moistening  and  applying  the  splint. 

The  surgical  gauze  marketed  in  loo-yard  bolts  will  be  found  most  con- 
venient.    The  ordinary  cartons  of  five  and  ten  }-ards  cannot  be  used. 

183 


i84 


SURGICAL   NURSING 


Fig.  131. — Supplies  Required  for  Plaster  Cast. 

The  following  supplies  will  be  required  (the  numbers  which  precede  in 
the  list  refer  to  the  numbered  articles  shown  in  Fig.  131) : 

1.  Gauze  bandages,  assorted,  width  3  to  3 3^^  inches,  six  or  seven. 

2.  Adhesive  plaster,  width  2  inches,  two  or  three  yards. 

3.  Flour  sifter  to  remove  grit  or  lumps  from  plaster. 

4.  Ordinary  tape  measure  for  measuring  limb. 

5.  Pulley  for  extension. 

6.  Two  granite  basins. 

7.  Bandage  scissors. 

8.  Block  and  rope  for  extension. 

9.  Manila  or  wrapping  paper  for  pattern,  sheet  25  by  48  inches. 

10.  Jar  of  water. 

11.  Absorbent  or  fracture  cotton,  one  or  two  rolls. 

12.  Surgical  gauze,  25  yards. 

13.  Dental  plaster,  50  pounds. 

14.  Spatula  or  case  knife. 

Measurement  of  the  Limb. — The  splint  is  so  made  that  it  fits  the  limb 
and  may  be  readily  molded  to  it.  To  secure  such  adaptation  each  splint 
calls  for  measurements  of  the  limb  to  which  it  is  to  be  applied.  The  fol- 
lowing measurements  are  necessary  to  draft  a  pattern  for  the  splint. 

Let  us  assume  that  we  have  a  fracture  at  the  middle  of  the  tibia,  and 
the  surgeon  desires  to  apply  a  posterior  splint.  In  order  that  complete 
immobilization  of  the  fracture  may  be  secured,  the  splint  must  extend 
from  the  toes  to  at  least  three  or  four  inches  above  the  knee-joint.  The 
measurements  to  be  taken  are: 

I .  The  total  length  of  the  splint  from  four  inches  above  the  knee  to  the 
ball  of  the  foot. 


THE   PLASTER-OF-PARIS    SPLINT 


185 


2.  Three-fourths  the  circumference  of  the  thigh,  four  inches  above  the 
knee.  This  measurement  will  represent  the  width  of  the  upper  end  of  the 
sphnt. 

3.  The  distance  from  the  upper  end  of  the  splint,  four  inches  above  the 
knee,  to  the  middle  of  the  knee-joint. 

4.  Three-fourths  the  circumference  of  the  leg  at  the  knee-joint. 

5.  The  distance  from  the  middle  of  the  knee-joint  to  the  greatest 
circumference  of  the  calf  of  the  leg. 


DISTANCE  FROM  TOP 
TO  JUST   MIDDLE 
OF  KNEE 


DISTANCE    FROM 

ABOVE   KNEE   TO 

CALF 


MEASUREMENl 


DISTANCE    FROM 

ANKLE     TO    BALL 

OF    FOOT 


(TENSION    FOR    SHRINKAGE 

OR     FOR     PROTECTION 

OF  TOES 


riDTH  AT  BASE 


Fig.  132. — Pattern  Completed  tor  the  Splint. 

6.  Three-fourths  the  circumference  of  the  calf  of  the  leg. 

7.  The  distance  from  the  calf  of  the  leg  to  the  ankle-joint. 

8.  Three-fourths  the  circumference  of  the  leg  at  the  ankle-joint. 

9.  The  distance  from  the  ankle-joint  to  the  ball  of  the  foot. 

10.  The  width  of  the  ball  of  the  foot.     This  measurement  will  represent 
the  width  of  the  lower  end  of  the  splint. 

It  is  well  to  extend  the  total  length  of  the  spHnt  one  or  two  inches  to 
allow  for  shrinkage  and  to  permit  molding  over  the  ends  of  the  toes.  If 
desired,  the  extra  length  can  be  cut  off  at  the  time  of  application. 


i86 


SURGICAL    NURSING 


Fig.  133.- — The  Nurse  Cutting  Twenty  Layers  oe  Gauze  for  Two  Forms. 


Fig.  134. — Sifting  Plaster  onto  Gauze  on  Plaster  Bed. 
Note  cut  gauze  in  foreground. 


THE   PLASTER-OF-PARIS    SPLINT 


187 


Fig.  135. — Impregnating  Gauze  Layer  by  Layer  with  Plaster. 

The  plaster  is   worked   into   the   meshes   of  gauze   with  spatula  or  case  knife.     One  form  of  id's 

completed  and  placed  between  cardboard  at  the  left. 


Fig.  136. — Two  Forms  of  io's  Completed. 


SURGICAL   NURSING 


After  taking  these  measurements  you  will  have  a  record  somewhat 
similar  to  this: 


Total  length,  31  inches 

Width  at  top,  8  inches 

From  top  to  knee,  5  inches 

Width  at  knee,  7  inches 

From  knee  to  calf  of  leg,  9  inches 


Width  at  calf  of  leg,  s^i  inches 
From  calf  of  leg  to  ankle,  9  inches 
Width  at  ankle,  4  inches 
From  ankle  to  ball  of  foot,  8  inches 
Width  at  ball  of  foot,  sJ-^  inches 


Making  the  Pattern. — Manila  or  heavy  wrapping  paper  is  the  most 
suitable  material  for  the  pattern.  A  piece  two  feet  wide  and  from  three  to 
four  feet  long  will  be  amply  large. 

The  paper  should  be  spread  out  upon  a  smooth  surface  and  a  center 
line  drawn  a  little  longer  than  the  required  splint.  At  the  upper  end  of 
the  center  line  draw  a  cross  line  equal  to  the  width  of  the  upper  end  of 
the  splint.  Measure  down  the  center  line  the  length  required  to  reach  the 
knee,  and  at  this  point  draw  another  cross  line  equal  to  the  measurement 
for  the  knee-joint.  From  the  intersection  of  these  lines  again  measure 
down  the  center  and  draw  another  cross  line  equal  in  length  to  the  meas- 
urement recorded  for  the  calf  of  the  leg.  In  a  similar  manner  designate 
the  distance  to  the  ankle  and  draw  a  cross  line  the  length  of  that  measure- 
ment. The  last  measurement  on  the  center  line  is  the  distance  from  the 
ankle  to  the  ball  of  the  foot;  at  this  point  draw  a  cross  line  equal  to  the 
width  of  the  foot  at  the  ball.  As  previously  stated,  it  is  well  to  make  the 
splint  one  or  two  inches  longer  to  provide  for  shrinkage,  and  this  extra 
length  should  be  added  to  the  lower  end  of  the  pattern.  The  pattern  is 
then  completed  by  lines  connecting  the  ends  of  the  cross  lines.  When  the 
drawing  is  cut  out,  you  have  a  pattern  (Fig.  132)  for  cutting  the  gauze  for 
the  splint. 

Cutting  the  Gauze. — Plaster-of-Paris  splints  ordinarily  consist  of  from 
one  to  three  forms  of  six,  eight,  ten,  or  twelve  layers  of  gauze  impregnated 
with  dry  plaster.  The  number  and  thickness  of  each  form  is  determined 
by  the  size  and  strength  desired  for  the  splint.  They  are  spoken  of  as 
6's,  8's,  lo's,  or  12's.  Your  instruction  from  the  surgeon  may  be,  "Pre- 
pare two  forms  of  lo's."  This  means  that  you  are  to  make  two  forms, 
each  of  ten  layers  of  gauze  impregnated  with  plaster. 


THE   PLAS'IER-Or-PARIS    SPLINT 


189 


The  surgical  gauze  is  spread  out  on  a  smooth  surface  so  as  to  have  its 
first  length  extend  one  or  two  inches  beyond  the  length  of  the  paper 
pattern.  It  is  then  folded  back  and  forth  upon  itself  to  provide  the  num- 
ber of  layers  that  may  be  required  for  the  forms  ordered.     For  illustration, 


Fig.  137. — Shaving  the  Limb  Preparatory  to  Application  of  Adhesive  Plaster  for  Extension 


X 


Fig.  138. — ^Attachment  of  Adhesive  Plaster  with  Block  and  Rope  for  Extension. 


suppose  that  you  are  to  make  a  splint  of  two  forms  of  ten  layers  each.  The 
gauze  would  then  be  folded  upon  itself  twenty  times.  It  is  well  to  add  a 
few  extra  layers  so  that  there  will  be  an  ample  supply.  As  each  fold  of 
gauze  is  laid  care  must  be  taken  that  all  wrinkles  are  smoothed  out. 


190 


SURGICAL   NURSING 


The  pattern  is  then  pinned  over  the  layers  of  gauze  (Fig.  133)  and  the 
gauze  cut  out. 

Impregnating  the  Gauze  with  Plaster. — A  thick  bed  of  plaster,  long 
enough  and  wide  enough  for  the  required  splint,  is  spread  evenly  upon  the 


Fig.  139. — Padding  the  Limb  with  Cotton- 


Fig.  140. — Entire  Limb  Covered  with  Cotton, 

table.  A  single  layer  of  gauze  is  laid  upon  the  plaster  bed,  and  plaster-of- 
Paris  sifted  over  it  (Fig.  134)  and  then  worked  into  it  with  a  spatula  or 
case  knife  (Fig.  135).  Another  layer  of  gauze  is  laid  exactly  over  the  first 
one  and  the  plaster  sifted  over  and  worked  into  it  in  a  like  manner.     In 


THE   PLASTER-OF-PARIS    SPLINT  I91 

this  way  the  successive  layers  are  built  up  on  top  of  each  other  until  the 
required  number  for  the  iorm,  8's,  lo's,  or  12's,  are  prepared.  The  layers 
which  constitute  the  form  are  then  taken  up  out  of  the  plaster  bed,  e7i 
masse,  folded  upon  themselves  two  or  three  times,  and  laid  away  between 
paper  or  cardboard  (Fig.  136).  Each  form  is  made  in  the  same  manner, 
folded,  and  put  aside  until  called  for  by  the  surgeon. 

The  remaining  steps  of  the  work  are  carried  out  under  the  personal 
direction  of  the  surgeon. 

Preparing  the  Limb.^ — The  fracture  having  been  reduced,  the  Hmb  is 


I 


Fig.  141. — Cotton  Padding  Held  in  Place  by  Gauze  Bandage. 
The  limb  is  ready  for  the  application  of  the  cast, 

prepared  for  the  splint.  If  extension  is  to  be  applied,  the  first  step  is  to 
apply  the  adhesive  plaster  for  the  attachment  of  the  extension  weights. 
When  necessary,  the  hair  on  the  limb  is  shaved  off  over  a  surface  equal 
to  the  length  and  width  of  the  adhesive  plaster  (Fig.  137).  The  bony 
prominences  over  the  ankle  should  be  well  padded  with  cotton,  and  the 
adhesive  applied  as  illustrated  in  Fig.  138. 

After  the  adhesive  extension  straps  are  in  place  the  entire  limb  is 
enveloped  in  absorbent  cotton  (Fig.  140)  maintained  in  place  by  a  single 
layer  of  a  gauze  bandage  (Fig.  141).  Ample  padding  must  be  placed  under 
the  heel  to  prevent  pressure  sores  (Fig.  139).     A  thick  cotton  pad  is  also 


192 


SUEGICAL   NURSING 


Fig.  142. — Gauze  Form  Impkegnated  with  Dry  Plaster  About  to  be  Immersed  in  Water. 


Fig.  143. — Excess  of  Water,  being  Wrung  trom  Gauze  Form. 


IHE    PLASTER-OF-PARIS    SPLINT 


Fig.  I44-— Impregnating  a  Form  with  Plaster  Paste  to  Add  to  Its  Strex 


Fig.  145. — Form  Ready  to  Apply  to  Lim 


194 


SURGICAL   NURSING 


placed  under  the  knee.     The  hmb  is  now  ready  for  the  application  of  the 
plaster  spHnt. 


Fig.  146. — Applying  the  Form  to  Limb. 
The  splint  is  made  to  conform  to  contour  of  limb  by  molding  in  place  with  hand. 


^^^X 


.J%- 


~«*<i»c. 


Fig.  147. — Bandaging  the  Cast  in  Place. 

Application  of  the  Splint. — A  thin  paste  is  prepared  in  one  of  the  basins 
by  mixing  plaster-of-Paris  with  water.  A  form  is  immersed  in  water 
(Fig.  142)  until  thoroughly  soaked.     It  is  then  lifted  out,  and  the  excess 


THE   PLASTER-OF-PARIS    SPUNT 


195 


of  water  wrung  out  (Fig.  143).     The  wet  form  is  spread  out  upon  a  smooth 
surface,  and  dry  plaster  or  plaster  paste  is  rubbed  into  it  (Fig.  144)  on 


Fig.  148. — Limb  Immobilized  in  Cast  with  Extension  Applied. 


Fig.  149. — Cutting  the  Bandages  that  Hold  the  Lijib  in  the  Cast. 

both  sides  until  the  meshes  of  the  gauze  are  full  of  plaster.  This  form 
(Fig.  145)  is  then  applied  to  the  limb.  The  second,  and,  if  used,  a  third 
form  is  prepared  in  a  similar  manner.     The  plaster-of-Paris  paste  pre- 


196 


SURGICAL  NURSING 


Fig.  150. — Dressing  Removed  to  Allow  Inspection  without  Disturbing  Alignment  of  the 

Limb. 


Fig.  151. — Padding  and  Splint  Removed  from  the  Limb. 
The  illustration  at  the  left  shows    the    padding   used    to   protect    the    bony   prominences, 
figure  at  the  right  shows  how  the  splint  is  molded  to  the  contour  of  the  limb. 


The 


THE   PLASTER-OF-PARIS    SPLINT  1 97 

viously  prepared  is  used  to  strengthen  any  portion  of  the  form  that  may 
require  reenforcement  after  it  has  been  applied  to  the  limb  (Fig.  146). 

If  but  two  forms  are  used  they  may  be  placed  together  before  applying 
them  to  the  limb. 

These  forms  are  so  molded  to  the  limb  as  to  conform  to  its  contour  and 
are  held  in  place  by  means  of  a  gauze  bandage  (Fig.  147). 

An  encircling  cast  of  plaster-of-Paris  is  now  but  seldom  used.  In 
addition  to  being  cumbersome  and  difficult  to  remove  it  does  not  permit 
inspection  of  the  limb.  A  splint  permits  frequent  inspection.  All  that 
is  required  is  to  cut  the  encircling  gauze  bandage  (Fig.  149),  turn  back 
these  cut  ends,  and  the  entire  limb  may  be  inspected  (Fig.  150).  The 
limb  may  be  removed  from  the  splint,  repadded,  and  the  splint  replaced. 
This  may  be  done  as  frequently  as  desired  without  the  necessity  of  making 
a  new  splint.  As  the  muscles  atrophy  from  disuse  and  the  limb  becomes 
more  movable  within  the  splint,  it  may  be  firmly  fixed  again  by  the  addition 
of  cotton  padding  to  its  inner  surface. 

Such  a  splint  is  very  convenient  if  a  fracture  is  complicated  by  an 
open  wound  that  requires  daily  dressing  or  treatment. 

If  an  anterior  splint  is  required  it  is  made  in  the  same  manner  as  is  the 
posterior  splint.     The  steps  of  application  are  also  identical. 

POINTS  TO  BE  OBSERVED 

Use  an  abundance  of  plaster  and  work  it  thoroughly  into  all  the  meshes 
of  the  gauze. 

Do  not  apply  the  forms  while  they  are  very  wet.  Wring  out  the  water 
and  then  rub  in  dry  plaster  or  plaster  paste  to  give  greater  strength. 

If  dental  plaster  is  used  one  must  work  rapidly  or  the  forms  will  set 
before  they  are  applied. 

Pad  all  bony  prominences  heavily  to  prevent  pressure  sores. 

Do  not  move  the  limb  for  at  least  an  hour  after  the  splint  has  been 
applied.     Allow  it  to  harden  through  its  entire  thickness. 

Plaster  work  is  "mussy."  The  floor  and  bedding  should  be  protected 
by  newspapers. 


CHAPTER  XVII 
CATHETERIZATION 

Catheterizing  the  bladder  must  always  be  considered  a  sterile  proce- 
dure, and,  as  such,  aseptic  precautions  must  be  observed  whenever  it  is 
performed.  The  bladder  is  peculiarly  susceptible  to  infection,  and  the  use 
of  an  unsterile  catheter  would  probably  be  followed  by  cystitis.  Such  a 
cystitis  will,  in  almost  every  instance,  be  a  most  distressing  condition, 
characterized  by  pain,  ardor  urinae,  frequent  micturition,  and  elevated 
temperature,  with  the  possibility  of  an  ascending  infection  of  the  ureter 
and  kidney  as  a  dire  complication. 

In  view  of  these  possibilities,  the  warning  cannot  be  uttered  too  fre- 
quently to  thoroughly  impress  nurses- with  the  dangers  that  may  attend 
the  use  of  an  unsterile  catheter.  The  emergency  does  not  exist  when  the 
use  of  an  unsterile  catheter  is  in  the  least  justified.  The  technique  of 
sterilizing  a  catheter  and  performing  catheterization  is  so  simple  and  the 
time  consumed  in  making  the  sterile  preparations  so  small  that  neglecting 
to  do  so  merits  nothing  but  severe  condemnation  and  the  immediate 
dismissal  of  a  nurse. 

Catheterization  may  be  divided  into  the  following  distinct  steps. 

Sterilization  of  the  Catheter. — The  catheter  or  catheters  are  rendered 
sterile  by  boiling  over  a  stove,  hot-plate,  or  alcohol  burner  for  a  period  of 
not  less  than  ten  minutes.  It  is  always  well  to  prepare  at  least  two  or 
three  catheters  to  provide  against  the  possibility  of  one  becoming  con- 
taminated or  its  lumen  obstructed. 

A  good  selection  is  one  glass  and  two  rubber  catheters.  Sterile  cotton 
will  be  required,  and  this  may  be  provided  by  boiling  several  balls  of 
absorbent  cotton  at  the  same  time  the  catheters  are  boiled.  Rubber 
gloves  are  desirable  and,  if  used,  they  also  may  be  boiled  at  the  same  time. 
In  addition,  sterile  oil  will  be  required  for  lubricating  the  catheter; 
ordinary  olive,  or  sweet,  oil  is  found  to  be  very  satisfactory.     Its  steriliza- 


CATHETERIZATION 


199 


tion  may  be  accomplished  by  boiling  it  in  its  container  in  a  basin  of^water. 
Alcohol,  70  per  cent.,  or  bichlorid,  i  in  1000,  and  a  basin  to  receive  the 
urine  that  is  withdrawn  complete  the  equipment. 


1 

^^ 

fl^3SKL^ 

^fl 

V        J 

1 

Fig.  152. — The  Equipment  for  Catheterization. 
Sterile  olive  oil,  70  per  cent,  alcohol,  basin  for  boiling,  rubber  and  glass  catheters,   cotton  swabs, 

and  receptacle  for  urine. 

Sterilization  of  the  Hands. — The  hands  should  be  thoroughly  scrubbed 
and  immersed  in  alcohol  or  bichlorid.  Rubber  gloves  that  are  sterile 
add  to  the  security  of  the  procedure. 


Fig.  153. — Sterilizing  Catheters  and  Cotton  Balls. 
If  desired,  the  rubber  gloves  may  be  boiled  at  the  same  time. 

Catheterization. — The  bladder  should  be  catheterized  under  direct 
inspection.  To  attempt  to  do  so  under  cover  is  impossible  without  the 
contamination  of  the  catheter.     The  patient  is  draped  as  for  a  vaginal 


200 


SURGICAL   NURSING 


examination,  and  is  requested  to  separate  the  limbs  a  reasonable  distance. 
If  desired,  she  may  flex  the  knees. 

With  the  left  hand  the  nurse  separates  the  labia  to  expose  the  urethral 
meatus.  The  orifice  of  the  meatus  is  wiped  with  pieces  of  sterile  cotton 
and  local  secretions  thoroughly  removed.  With  a  fresh  piece  of  cotton 
^moistened  in  alcohol  or  bichlorid  the  meatus  is  again  cleansed. 

The  catheter  is  then  taken  from  the  basin  in  which  it  was  boiled. 
In  doing  so,  never  touch  the  end  or  nearer  than  three  inches  to  the  end  that 
is  to  be  inserted.     The  catheter  is  dipped  into  the  sterile  oil,  and  the  excess 


Fig.  154. — The  Nurse  is  Removing  Sterilized  Catheter. 

oil  permitted  to  drip  off.  The  catheter  is  then  inserted  into  the  meatus, 
and  by  gentle,  steady  pressure  its  entrance  into  the  bladder  is  accom- 
plished. When  the  catheter  enters  the  bladder,  the  urine  will  flow  into 
the  basin  previously  placed  to  receive  it. 

The  bladder  emptied,  the  rubber  catheter  is  pinched  sufficiently  to  close 
its  lumen  and  withdrawn.  If  a  glass  catheter  is  used,  cover  the  end  while 
withdrawing  it. 

Some  surgeons  direct  that  after  each  catheterization,  before  the  cathe- 
ter is  withdrawn,  one  or  two  drams  of  a  2  per  cent,  solution  of  argyrol  be 
injected  into  the  bladder  and  permitted  to  remain.  If  such  are  the  in- 
structions, the  argyrol  may  be  injected  through  the  catheter  by  means  of 
a  record  syringe  or  poured  into  a  small  funnel  attached  to  the  end  of  the 
catheter. 


CATHETERIZATION  201 

COMMENTS 

1.  The  hand  used  to  spread  open  the  labia  is  not  removed  during  the 
entire  procedure.  The  labia  are  held  retracted  during  the  process  of 
catheterization.  It  will  be  necessary,  therefore,  to  have  every  article 
that  is  required  within  easy  reach. 

2.  Do  not  entirely  empty,  at  one  catheterization,  a  bladder  that  is 
markedly  overdistended,  or  in  which  there  has  been  a  prolonged  retention. 
Remove  only  about  half  the  contents  at  the  first  catheterization. 

3.  Constant  dribbling  of  urine  or  frequent  desire  to  urinate,  with  the 
passing  of  only  a  small  quantity,  should  excite  suspicion  and  an  examina- 
tion should  be  made  to  determine  whether  the  condition  is  not  one  of 
overflow  of  a  distended  bladder  incapable  of  emptying  itself. 

4.  Catheterization  should  be  resorted  to  as  infrequently  as  possible. 
It  should  not  be  made  a  procedure  of  convenience.  Exhaust  every  other 
method  of  causing  a  bladder  to  empty  itself  before  catheterizing.  Cathe- 
terize  only  when  such  procedure  is  positively  indicated. 


CHAPTER  XVIII 

OPERATION  FOR  APPENDICITIS 
DUTIES  OF  THE  NURSE  IN  PREPARATION  AND  DURING  THE  POST-OPERATIVE  PERIOD 

In  the  foregoing  chapters  I  have  discussed  the  essentials  that  a 
nurse  should  know  when  assisting  in  operative  work.  For  the  purpose 
of  correlating  that  information  as  well  as  to  reveal  its  practical  applica- 
tion I  am  devoting  this  chapter  to  a  description  of  the  duties  of  a  nurse 
while  engaged  in  a  given  operation. 

In  the  preparation  of  this  chapter  I  have  borne  in  mind  that  it  will  be 
read  by  two  classes  of  readers — the  graduate  and  the  undergraduate  or 
pupil  nurse.  To  one,  many  of  the  details  will  be  familiar,  while  to  the 
other,  in  the  most  part,  this  chapter  will  give  new  light  and  information. 
By  reason  of  this  it  is  necessary  that  minor  details,  which  to  some  will 
appear  extremely  rudimentary,  be  touched  upon. 

NATURE  OF  THE  DISEASE 

In  order  that  a  nurse  may  be  able  to  care  intelligently  for  a  patient 
suffering  from  appendicitis  it  is  requisite  that  she  be  informed  as  to  its 
nature,  symptoms,  and  course.  Such  knowledge  will  enable  her  to  follow 
her  patient  through  his  illness  and  detect  at  their  very  onset  unfavorable 
symptoms  or  complications.  The  nurse  should  be  in  possession  of  the 
nature  and  course  of  the  condition  of  every  patient  for  whom  she  assumes 
the  responsibility  of  being  the  attending  nurse. 

Definition. — Appendicitis  is  an  acute,  subacute,  or  chronic  inflammation 
of  the  vermiform  appendix  producing  local  and  constitutional  symptoras 
of  definite  character. 

Cause. — Many  factors  may  unite  to  produce  it.  The  foremost  are 
constipation  and  digestive  disturbances,  bacterial  infections  producing 
acute  inflammation,  foreign  bodies,  principally  fecal  concretions,  catarrhal 
infections  causing  a  thickening  of  the  mucous  lining  of  the  appendix  and 
thereby  occluding  its  lumen  and  altering  its  blood  supply,  malformations, 
adhesions,  and,  rarely,  trauma. 


OPERATION   FOR   APPENDICITIS  203 


SYMPTOMS  OF  ACUTE  ATTACK 


Pain. — At  first  general  throughout  the  abdomen  and  often  mistaken 
for  intestinal  colic  and  indigestion.  This  pain  will  localize  in  from  four 
to  twenty-four  hours  and  be  of  greatest  intensity  in  the  right  iliac  fossa 
over  what  is  called  McBurney's  point.  The  patient  often  secures  relief 
by  lying  on  his  right  side  with  his  knees  drawn  up. 

Nausea. — Nausea  or  vomiting  will  follow  the  pain  either  with  its  onset 
or  within  a  few  hours.  In  true  appendicitis  the  pain  is  first,  then  nausea  or 
vomiting,  and  not  nausea  or  vomiting  and  then  pain.  The  nausea  may  be 
of  but  slight  degree  and  consist  only  of  a  sick  feeling,  and  again  there  may 
be  continuous  vomiting  and  retching,  severely  aggravated  by  the  taking 
of  water  or  nourishment  and  the  administration  of  medicines  or  cathartics. 

Tendemess.-^The  tenderness  on  pressure  may  at  first  be  general 
through  the  entire  abdomen  but  becomes  localized  in  the  right  iliac  fossa 
in  from  two  to  twenty-four  hours.  Light  pressure  over  McBurney's  point 
with  the  finger  tips,  will  intensify  the  pain. 

Muscular  Rigidity. — On  palpation  the  muscles  will  be  found  rigid  and 
frequently  very  boardlike  with  a  prominence  of  the  right  rectus;  the 
muscles  of  the  abdomen  may  also  be  retracted  causing  a  scaphoid  abdomen. 
Again,  they  may  only  be  rigid  on  palpation;  their  rigidity  depends  much 
upon  the  severity  of  the  attack  and  nervous  sensibility. 

Temperature  and  Pulse. — These  are  not  infallible  in  making  a  diagno- 
sis. They  may  be  absolutely  normal  during  the  early  hours  or  days  of  the 
attack.  Again  at  the  very  onset  we  may  obtain  a  pulse  ranging  from  90 
to  120  with  a  normal  temperature  or  one  that  registers  100°  to  103°  or  104°. 
When  the  pulse  and  temperature  are  just  cause  for  alarm  the  local  condi- 
tion in  and  around  the  appendix  has  usually  advanced  to  a  grave  state. 
Again,  one  may  find  a  normal  pulse  and  temperature  with  a  gangrenous 
appendix  and  their  normal  state  be  not  altered  until  a  spreading  peritonitis 
ensues. 

Prostration. — This  may  be  marked  or  not.  One  patient  may  be 
desperately  ill  while  another  with  an  appendix  equally  bad  may  have  but 
little  prostration  and  not  appear  very  ill. 


204  SURGICAL   NURSING 

COMPLICATIONS 

Appendicitis  is  a  most  treacherous  disease  and  may  terminate  in  the 
following  ways:  Convalescence  uneventful;  the  formation  of  a  localized 
absce'ss;  gangrene,  sloughing,  and  perforation  of  the  appendix;  rupture  of 
the  appendix  or  a  formed  abscess  into  the  free  abdominal  cavity;  peri- 
tonitis, and  intestinal  obstruction.  These  complications  may  be  entirely 
prevented  if  the  disease  is  recognized  in  its  earliest  hours  and  the  only  now 
recognized  treatment,  the  removal  of  the  appendix  by  operation,  be 
promptly  resorted  to.  There  never  was  and  never  will  be  a  purely  medical 
method  of  treatment  in  which  safety  may  be  secured.  Cases,  we  admit, 
do  recover  under  medical  treatment,  but  there  often  follows  a  long  invalid- 
ism characterized  by  digestive  disturbances,  pain,  nausea,  constipation, 
and  later  gall-bladder  involvement.  It  must  also  be  remembered  that 
every  death  from  appendicitis  might  have  been  prevented  if  the  diseased 
organ  had  been  promptly  removed;  not  as  a  last  resort  or  after  the  patient's 
condition  had  become  serious,  but  early,  in  the  first  twelve  hours  of  the 
disease. 

OPERATIVE  TREATMENT 

There  is  no  medical  treatment.  Safety  hes  in  early  and  prompt  re- 
moval. There  is  greater  risk  involved  in  not  operating  than  in  an  operation 
done  by  a  competent  and  experienced  surgeon.  He  who  attempts  to  treat 
appendicitis  by  medicinal  measures  or  any  measures  other  than  surgical 
is  assuming  a  heavy  responsibility.  The  patient  will  eventually  pay  a 
severe  penalty  either  by  the  bringing  on  of  complications  or  a  Hfe  of 
digestive  disturbances,  gall-bladder  infection,  debihty,  renal  disease  and 
much  suffering,  distress,  and  invalidism. 

NURSING  CARE:  PREOPERATIVE 

What  is  the  duty  of  a  nurse  upon  arriving  at  the  home  of  a  patient  who 
in  two  or  three  hours  is  to  undergo  an  operation  for  acute  appendicitis? 

The  Patient.— The  nurse  will  undoubtedly  be  ushered  into  a  home 
where  the  members  of  the  family  and  immediate  neighbors  are  in  a  greater 
or  less  stage  of  excitement  by  reason  of  the  impending  operation.  The 
exercising  of  a  httle  tact  and  a  rapid  sizing  up  of  the  situation  will  enable 


OPERATION   FOR  APPENDICITIS  205 

the  nurse  to  counteract  this  disordered  state  of  affairs.  Nothing  will 
bring  about  order  and  quiet  more  rapidly  than  by  asking  everyone,  except 
possibly  one  or  two  close  relatives,  to  leave  the  sickroom  and  to  assign  to 
certain  members  of  the  family  the  performance  of  work  in  assisting  to 
prepare  for  the  operation.  A  word  here  and  there  of  encouragement  and 
assurance  will  soon  create  a  feeling  of  confidence  and  quietude. 

The  patient,  suffering  more  or  less,  depending  upon  whether  he  has  had 
an  opiate  or  not,  should  be  told  that  certain  things  must  be  made  ready  and 
that  his  cooperation  and  compliance  with  orders  will  increase  the  success  of 
the  operation.  After  taking  his  temperature  and  pulse  and  recording  it, 
he  should  be  given  a  cleansing  bath.  While  giving  the  bath  the  patient's 
confidence  and  repose  may  be  more  firmly  secured  if  the  nurse  will  explain 
to  him  in  more  or  less  detail  just  what  he  may  expect  and  the  experiences 
which  he  is  to  undergo.  An  operation,  no  matter  how  small  or  great,  is 
always  a  more  or  less  formidable  undertaking  to  any  person,  and  it  is  no 
more  than  right  that  groundless  fears  and  suspicions  be  caused  to  vanish 
by  a  calm  and  plain  statement  of  facts.  This  conversation  should  not  be 
characterized  by  boasting  tales  of  operative  work  or  revolting  experiences 
or  gossip;  to  reiterate,  it  should  be  a  calm,  sensible  statement  of  uncolored 
facts. 

The  bath  completed,  the  abdomen  is  to  be  shaved.  As  a  rule  no 
enemas  are  given  unless  by  special  order  from  the  surgeon;  the  patient  is 
not  catheterized  if  he  is  able  to  void  urine.  By  reason  of  the  irritability 
of  the  stomach,  common  in  this  disease,  nothing  is  to  be  given  by  mouth; 
he  may,  however,  be  permitted  to  frequently  rinse  his  mouth.  This 
done,  a  clean  gown  is  put  on  and  the  bed  is  made  up  with  clean  linen.  The 
patient  is  now  urged  to  lie  as  quietly  and  comfortably  as  possible  while 
the  nurse  directs  her  attention  toward  the  preparation  of  the  room  in 
which  the  operation  is  to  be  performed. 

The  Room. — Before  giving  the  patient  his  bath  the  nurse  will  have 
instructed,  as  suggested  above,  certain  members  of  the  family  to  remove 
the  furniture,  wall  decorations,  curtains,  and  rugs  from  the  operating 
room.  Newspapers  are  now  spread  over  the  floor  and  over  these  there 
is  spread  a  large  sheet,  tacked  to  the  floor  at  its  corners  and  at  one  or 


206  SURGICAL   NURSING 

two  places  along  the  edge.  The  lower  sashes  of  the  windows  are  covered 
with  sheets  or  newspapers  and  light  permitted  to  enter  through  the  upper 
sashes  alone.  The  dining  table  and  two  or  three  smaller  tables  and  chairs 
are  carried  in  and  arranged  as  suggested  on  page  23.  The  room  may 
then  be  considered  as  ready  in  so  far  as  the  floor,  furniture,  and  light  are 
concerned;  nothing  more  can  be  done  to  it  until  the  "kit"  of  sterile  goods 
and  instruments  arrive. 

Water. — Several  gallons — five — of  water  should  be  put  on  to  boil 
and  two  or  three  gallons  of  sterile  cool  water  are  to  be  provided.  Several 
hand  basins  may  well  be  sterilized  by  boiling  in  a  wash  boiler.  Unless 
one  has  two  or  three  hot-water  bottles  several  fruit  cans  should  be  made 
ready  to  serve  instead  of  hot-water  bottles  when  needed. 

By  the  time  the  foregoing  has  been  accomplished  the  "kit"  and 
surgeon's  nurse  will  have  arrived.  It  is  now  that  the  preparation  becomes 
more  active. 

Unpacking  the  Kit  and  "Setting-up."— The  supplies  that  are  contained 
in  the  kit  are  to  be  unpacked  and  arranged  in  orderly  piles  upon  a  supply 
table  that  is  out  of  the  way,  but  within  easy  access.  While  this  is  being 
done  the  surgical  nurse  will  be  scrubbing  up,  and  donning  sterile  gown  and 
gloves.     The  instruments  are  put  on  to  boil. 

The  unscrubbed  nurse  opens,  in  the  proper  way,  the  packages  of  sterile 
goods  and  hands  their  contents  to  the  clean  nurse.  The  first  package  to 
be  opened  is  that  which  contains  sterile  draping  sheets  in  order  that  all 
the  tables  may  be  covered  with  sterile  covers  and  so  protect  the  supplies 
that  are  to  be  arranged  upon  them.  One  after  another  the  several 
packages  are  opened  and  their  contents  handed  to  the  clean  nurse  who 
suitably  arranges  them.  One  or  two  floor  basins  are  arranged  for  the 
receiving  of  soiled  dressings  and  for  fluids.  The  instruments  are  brought 
in  and  given  to  the  clean  nurse  who  dries  them  with  a  sterile  towel  and 
arranges  them  in  an  orderly  manner  upon  the  instrument  table.  The 
surgeons  have  now  arrived  and  they  should  be  provided  with  brushes, 
soap,  and  plenty  of  water  for  scrubbing  up.  The  unscrubbed  nurse 
assists  them  in  putting  on  their  headgears  and  face  masks  and  assures 
herself  that  they  are  provided  with  plenty  of  scrub  water  and  that  the  hand 


OPERATION   FOR    APPENDICITIS  207 

basins  contain  their  proper  solutions  for  the  final  cleansing  of  the  operator's 
hands.  She  then  returns  to  her  patient  and  remains  with  liim  until  he  is 
carried  to  the  table.  It  is  possible  that,  unless  he  has  had  one,  the 
surgeon  will  order  that  the  patient  receive  a  hypodermic  of  morphin  and 
atropin.  This  given,  the  stockings  are  put  on  and  his  head  covered  with 
a  towel  or  cap.     The  temperature  and  pulse  are  again  taken  and  recorded. 

OPERATION 

Under  the  direction  of  the  nurse  the  patient  is  carried  to  the  operating 
table  by  two  of  the  members  of  the  family  or  neighbors.  With  the  com- 
mencement of  the  administration  of  the  anesthetic  the  unclean  nurse 
uncovers  the  abdomen  and  surrounds  it  with  sterile  towels.  She  next 
performs  the  first  step  of  preparing  the  operative  field  by  thoroughly 
cleansing  it  with  a  solution  of  benzin  with  iodin — i  part  of  crystals  of 
iodin  to  looo  parts  of  benzin.  When  this  has  been  permitted  to  evapo- 
rate the  clean  nurse  will  paint  the  entire  abdomen  with  tincture  of  iodin — 
50  per  cent,  solution  in  alcohol — and  drape  the  field  with  sterile  towels  and 
sheets.  The  unscrubbed  nurse's  immediate  duties  with  the  patient  are 
over  for  the  present  and  she  holds  herself  in  readiness  to  perform  the  fol- 
lowing tasks: 

Duty  of  the  Unscrubbed  Nurse  during  Operation. — 

1.  To  see  that  the  house  is  quiet  and  no  disturbing  noises  exist. 

2.  To  be  in  readiness  to  hand  the  clean  nurse  additional  supplies, 
dressings,  or  solutions. 

3.  To  assist  the  anesthetist  as  she  may  be  requested. 

4.  To  keep  watch  of  and  count  all  soiled  dressings  or  materials  falling 
or  thrown  upon  the  floor. 

5.  To  observe  the  clean  nurse's  count  of  sponges  and  instruments  when 
the  surgeon  is  about  to  close  the  wound. 

6.  To  prepare  the  patient's  bed  and  fill  two  or  three  hot-water  bottles. 

7.  To  assist  the  clean  nurse  in  applying  the  abdominal  binder. 

8.  To  superintend  the  patient's  return  to  bed. 

Duty  of  the  Scrubbed  or  Clean  Nurse  during  Operation. — The  tech- 
nique of  aseptic  surgery  as  taught  to  the  nurse  during  her  training  is  to  be 


208  SURGICAL   NURSING 

carefully  observed  and  rigidly  carried  out.  In  operations  performed  in 
private  homes  greater  vigilance  and  precautions  are  to  be  exercised 
than  in  a  hospital  on  account  of  the  increased  danger  of  contact  with  non- 
sterile  articles  and  objects.  The  clean  nurse  must  be  constantly  on  the 
alert  and  watch  her  every  movement  and  exercise  double  precautionary 
care  to  prevent  contamination. 

Having  donned  her  headpiece  and  face  mask  she  scrubs  up  with  soap 
and  sterile  water  and  lastly  submits  her  hands  and  forearms  to  a  thorough 
immersion  in  70  per  cent,  alcohol.  A  sterile  gown  is  then  handed  to  her 
by  the  unscrubbed  nurse  who  opens  its  outer  container  so  that  the  clean 
nurse  can  take  the  clean  gown  from  it  without  coming  in  contact  with 
this  outer  protecting  cover.  The  gown  is  fastened  in  the  back  by  the  un- 
scrubbed nurse.  Rubber  gloves  are  then  put  on.  It  is  an  excellent  safe- 
guard for  the  clean  nurse  to  put  on  two  pairs  of  rubber  gloves,  one  over  the 
other.  The  outer  pair  is  taken  off  when  the  patient's  table  preparation  is 
complete.  By  so  doing  the  second  pair  of  gloves  that  are  worn  during  the 
actual  operative  work  do  not  come  in  contact  with  anything  previous 
to  the  handling  of  dressings,  sponges,  sutures,  and  instruments.  It  is 
certainly  a  commendable  precaution  and  an  excellent  step  in  surgical 
technique. 

Thus  robed,  the  clean  nurse  arranges  the  dressings,  sponges,  sutures, 
and  instruments  upon  the  instrument  and  dressing  tables  as  they  are 
handed  to  her  by  the  unscrubbed  nurse — never  trust  to  memory,  always 
write  down  the  number.  After  having  these  supplies  and  instruments 
arranged  in  accessible  order,  the  needles  that  are  to  be  used  are  threaded 
with  their  suture  material — catgut,  Nos.  2,  3,  and  4,  silkworm  gut,  and 
linen.  Extra  catgut  sutures  and  ligatures  are  immersed  in  a  basin  con- 
taining 70  per  cent,  alcohol. 

When  the  patient  is  placed  upon  the  table  and  the  abdomen  has  been 
uncovered  and  scrubbed  with  the  iodin-benzin  solution — ^i  in  1000 — 
and  draped  with  the  sterile  towels  by  the  unscrubbed  nurse,  the  clean 
nurse  paints  the  entire  abdomen  with  a  50  per  cent,  tincture  of  iodin  in 
alcohol  by  means  of  a  gauze  sponge  held  by  a  sponge-holder.  The  chest 
and  limbs  are  covered  with  sterile  sheets  and  the  operative  field  surrounded 


OPERATION   POR   APPENDICITIS  209 

with  sterile  towels  maintained  in  place  by  means  of  safety  pins  or  towel 
clips.  The  patient  has  now  been  properly  draped  and  everything  is  in 
readiness  for  the  surgeon  to  commence  his  operative  work.  If  the  nurse 
has  worn,  up  to  this  time,  two  pairs  of  rubber  gloves,  it  is  now  that  she 
discards  the  outer  pair  and  passes  her  other  pair  of  gloves  through  a  solu- 
tion of  alcohol.  The  operative  work  commenced,  the  clean  nurse's  duties 
consist  of  supplying  the  surgeon  and  his  assistants  with  clean  sponges, 
holding  retractors  when  so  requested,  to  see  that  all  exposed  intestines  are 
kept  covered  with  hot,  moist  saline  squares,  to  hand  to  the  surgeon  the 
sutures,  ligatures,  and  needles  called  for  and  the  various  instruments  that 
are  used.  She  should  also  see  that  the  surrounding  field  is  kept  clean  by 
the  placing  of  sterile  towels  whenever  those  that  are  in  place  become  badly 
soiled.  No  definite  or  consecutive  steps  of  duty  can  be  described.  There 
is  only  one  rule  to  follow  and  observe — to  aid  in  every  possible  way  to  ex- 
pedite the  surgeon's  work  by  anticipating  his  wants  and  having  ready  for 
him  that  which  he  may  require  without  his  having  to  ask  or  wait  for  it. 
One's  ability  to  do  this  stamps  one  as  an  excellent  or  only  a  mediocre 
surgical  nurse;  intense  concentration  and  watchfulness  alone  bring  to  the 
nurse  this  perfection  and  ability. 

The  appendix  removed,  the  stump  inverted  and  covered  over,  the  coil 
of  intestine  returned  to  the  abdomen,  and  the  surgeon  about  ready  to 
close  the  wound  should  find  the  nurse  prepared  to  inform  the  surgeon  that 
everything  has  been  accounted  for.  She  hands  him  a  curved  needle 
with  No.  I  or  No.  2  catgut,  in  a  holder,  for  closing  the  peritoneum.  Next 
she  has  ready  six  large  curved  needles  threaded  with  silkworm  gut  for  ten- 
sion sutures;  thereafter  the  surgeon  is  supplied  with  small  curved  needles 
threaded  with  No.  3  catgut  for  closing  the  muscles  and  fascia;  lastly,  he  is 
given  a  skin  needle  threaded  with  No.  3  catgut  for  closing  the  skin. 

The  wound  sutured  in  its  entirety,  a  moist  saline  sponge  is  used  to 
cleanse  the  skin;  the  wound  is  covered  with  the  customary  dressing  main- 
tained in  place  by  adhesive  plasters;  a  pad  and  abdominal  binder  put  on 
with  the  aid  of  the  unscrubbed  nurse  terminates  the  necessity  of  the  clean 
nurse  keeping  herself  sterile. 

The  patient  returned  to  bed,  the  clean  nurse  as  rapidly  as  possible 

14 


210  SURGICAL   NURSING 

cleans  up  and  while  doing  so  devotes  her  attention  to  the  performance  of  the 
following  duties : 

1.  Boils  and  dries  the  instruments  and  returns  them  to  the  surgeon's 
bag.  ' 

2.  Empties  out  all  solutions  and  dries  their  containers. 

3.  Packs  up  all  returnable  supplies  and  places  them  in  the  "kit." 

4.  Wraps  soiled  sponges  and  dressings  in  a  paper  ready  to  be  burned 
in  a  stove  or  furnace. 

5.  Gives  the  removed  appendix,  in  a  solution  of  alcohol  or  formalin, 
to  the  nurse  remaining  upon  the  case. 

6.  Secures  the  assistance  of  members  of  the  family  or  neighbors  to  set 
the  room  in  order  and  arrange  the  furniture  and  drapes  as  they  were  before 
the  operation. 

The  duties  of  the  clean  nurse  are  now  completed. 

POST-OPERATIVE  CARE 

Upon  his  return  to  bed  the  patient  is  immediately  surrounded  with  two 
or  three  hot-water  bottles — care  being  exercised  to  so  place  them  as  to 
prevent  causing  burns — and  covered  with  a  light  warm  sheet,  blanket, 
and  spread.  Do  not  load  on  extra  blankets.  The  patient's  head  is 
turned  slightly  to  one  side  and  if  required  his  jaw  is  supported  to  afford 
him  unimpeded  respiration.  No  pillow  is  to  be  used'  except  in  patients 
past  forty  with  spinal  curvature.  The  pulse  is  taken  every  ten  minutes 
and  its  rate  and  character  recorded  upon  the  chart.  As  consciousness 
returns  there  may  occur  some  vomiting  or  retching;  the  mouth  is  to  be 
kept  clean  of  all  such  vomitus  and  mucus.  Any  restlessness  or  tendency 
to  toss  about  must  be  prevented.  When  the  patient  is  far  enough  out 
of  the  anesthetic  to  understand,  he  should  be  informed  that  the  operation 
is  over,  that  he  is  back  in  bed,  and  with  a  few  reassuring  words  be  requested 
to  remain  quiet  and  rest.  The  room  is  darkened,  visitors  are  forbidden, 
and  the  immediate  relatives  are  admitted  only  for  a  few  moments.  Ab- 
solute quiet  should  be  insisted  upon  so  that  the  patient  may  be  benefited 
by  a  few  hours  sleep  and  rest.  An  ample  amount  of  fresh  air  must  be 
maintained. 


OPERATION   FOR   APPENDICITIS  211 

WHAT  TO  WATCH  FOR 

Shock. — If  occurring  either  early  or  delayed,  shock  should  receive 
prompt  and  energetic  treatment,  and  in  the  event  of  its  prolongation  or 
increasing  severity  and  nonresponse  to  preliminary  treatment  the 
surgeon  or  attending  physician  must  be  promptly  notified.  The  prelimi- 
nary treatment  and  the  precautionary  orders  commonly  given  are: 
morphin,  grain  ^i,  atropin,  grain  l{^o,  hypodermatically ;  strychnin, 
grain  I-^q?  or  camphorated  oil;  saline  enema;  local  heat  and  elevation  of 
the  foot  of  the  bed.  If  the  patient's  condition  under  this  treatment  does 
not  promptly  improve  the  surgeon  must  be  notified. 

The  Wound. — The  wound  must  be  protected  and  the  patient  prevented 
from  displacing  the  dressings.  The  dressings  should  be  inspected  fre- 
quently to  ascertain  that  they  are  properly  maintained.  The  patient 
will  undoubted!}^  complain  of  the  pain  or  smarting  in  the  wound  and  his 
comfort  may  be  enhanced  if  the  nurse  will  but  tell  him  that  such  sensations 
are  but  a  natural  sequence  of  the  operation  and  are  to  be  expected;  that 
these  sensations  will  disappear  in  a  few  hours  and  that  he  must  not  permit 
them  to  cause  him  any  worry.  At  times  and  in  some  individuals  the 
wound  is  extremely  painful  and  in  this  event,  if  the  above  encouragement 
does  not  allay  his  restlessness,  it  is  justifiable  to  administer  a  small  dose 
of  morphin.  Pain  in  the  wound  may  also  be  relieved  b}^  placing  a  pillow 
under  the  patient's  knees,  thus  relieving  and  relaxing  the  tension  of  the 
abdominal  muscles. 

COMPLICATIONS 

Barring  a  little  nausea,  pain,  and  distress,  the  patient  should  experi- 
ence an  uneventful  recovery.  However,  complications  can  and  may  ensue 
and  in  that  event  the  nurse  should  be  prompt  in  the  detection  of  their 
early  warning  symptomiS  and  thus  secure  prompt  treatment  by  reporting 
them  to  the  surgeon  as  early  as  they  are  detected. 

Vomiting. — In  an  emergency  appendectomy  the  opportunity  is  not 
afforded  for  the  usual  surgical  preparation  and  the  intestinal  tract  and 
often  the  stomach  are  not  in  as  satisfactory  a  state  as  we  ordinarily  desire 
them  to  be.     Added  to  that  condition,  the  administration  of  an  anesthetic 


212  SURGICAL   NURSING 

may  cause  rather  severe  post-operative  vomiting  and  nausea.  This 
usually  subsides  in  twenty-four  hours.  In  the  event  that  it  persists 
longer  than  this  several  conditions  must  be  suspected:  acute  dilatation 
of  the  stomach,  intestinal  obstruction,  and  peritonitis.  The  treatment  of 
vomiting  should,  during  the  first  Iwenty-four  hours,  consist  of  rest  and 
withholding  of  nourishment.  Sometimes  by  causing  the  patient  to  drink 
one  or  two  glasses  of  water  in  succession  his  vomiting  will  cleanse  the 
stomach  of  its  irritating  contents  and  thus  cause  the  vomiting  to  cease. 
If  the  vomiting  continues  longer  than  twenty-four  hours  it  should  not  be 
ignored  and  the  surgeon  will  undoubtedly  order  a  gastric  lavage.  In 
case  a  dilatation  exists  the  lavage  will  be  repeated  frequently.  Acute 
dilatation  is  characterized  by  continuous  or  frequent  vomiting,  distention, 
rapid  pulse,  and  gradual  but  appreciable  failure  of  strength. 

Presistent  vomiting  also  occurs  with  obstruction  and  in  general  peri- 
tonitis, the  symptoms  of  which  are  characteristic;  the  nurse  should  be 
familiar  with  their  nature  and  mode  of  onset. 

To  summarize :  If  vomiting  persists  longer  than  twenty-four  hours  one 
should  be  on  the  alert  to  discover  the  exact  exciting  factor  and  direct 
toward  it  the  proper  treatment. 

Distention  and  Gas  Pains. — The  exposure  of  the  abdominal  contents 
to  the  external  air,  the  handling  of  the  intestines  during  abdominal 
operations,  and  the  intestines  being  more  or  less  loaded  with  only  partially 
digested  foodstuffs,  together  with  the  effect  of  the  operative  procedure 
upon  the  nervous  system  serve  to  cause  what  are  commonly  called  gas 
pains  and  distention  of  greater  or  less  degree.  Simple  gas  pains  of  but 
transitory  duration  are  unworthy  of  much  consideration  as  they  cause 
but  a  few  hours  distress  and  are  readily  relieved.  However,  when  they 
persist  and  continue  beyond  the  first  or  second  day  and  have  added  thereto 
marked  abdominal  distention  they  then  merit  active  treatment.  Their 
nature  is  such  as  to  cause  nagging  and  frequently  recurring  cramps  which 
give  much  annoyance  and  an  uncomfortable,  full  feeling  and  thereby 
cause  a  more  labored  respiration  with  a  rapid  pulse  of  lOO  to  no  or  120- 
The  treatment  is  to  stimulate  the  arrested  peristalsis  by  means  of  enemata, 
and  if  necessary  a  dose  of  castor  oil  or  a  saline  cathartic.     Persistent 


OPERATION   FOR   APPENDICITIS  213 

distention  may  be  present  in  the  early  stages  of  peritonitis  and  it  is  essen- 
tial tliat  one  differentiate  between  peritonitis,  acute  gastric  dilatation,  and 
obstruction,  and  also  intestinal  paresis  or  arrested  peristalsis. 

Temperature. — After  twelve  hours  the  temperature  rises  to  99°  or  100°. 
At  the  end  of  twenty-four  hours  it  may  be  100.5°  ^^d  on  the  second  or 
third  day  may  reach  100°  to  101°.  When  three  or  four  days  elapse  it  will 
have  reached  a  normal  stage  with  only  a  slight  afternoon  elevation.  Such 
a  range  of  temperature  is  but  a  normal  post-operative  rise  and  is  sometimes 
called  a  surgical  fever.  When  the  temperature  persists  longer  than  three 
days  or  rises  to  a  higher  mark,  or,  when  there  is  a  morning  drop  and  an 
evening  elevation  to  101°  or  102°,  one  must  conclude  that  an  unnatural 
factor  is  present  and  is  causing  this  fever.  The  foremost  factors  are: 
Wound  infection,  intestinal  toxemia,  or  a  lung  complication.  A  tempera- 
ture existing  after  the  third  day  and  which  reaches  101°  or  higher  should 
be  immediately  reported.  A  chill  followed  by  a  rise  in  temperature  to 
101°  or  104°  denotes  an  infection  and  demands  that  the  wound  be  early 
inspected  by  the  surgeon.  A  persistent  subnormal  temperature  with  a 
pulse  of  100  to  no,  small  in  character,  should  also  be  promptly  reported. 
A  temperature  persisting  longer  than  three  days  is  as  a  rule  an  abnormal 
condition  and  demands  a  search  for  its  cause. 

Kidney  Secretion. — The  effect  of  the  administration  of  an  anesthetic 
plus  the  restriction  of  water  by  mouth  has  a  tendency  to  reduce  the  amount 
of  urine  secreted  during  the  first  forty-eight  hours  to  from  eighteen  to 
twenty-five  ounces  per  day.  In  some  instances  where  there  is  a  kidney 
involvement  or  from  the  anesthetic  the  after-effects  of  the  operation  may 
cause  an  acute  hyperemia  of  the  kidney  and  also  an  acute  nephritis  with 
the  consequent  suppression  of  urine  to  only  three  or  four  ounces  per  day. 
If  this  condition  is  permitted  to  exist  undetected  uremic  poisoning  will 
ensue.  Consequently  it  is  very  essential  that  the  amount  of  urine 
secreted  post-operatively  should  be  carefully  measured  and  the  total 
twenty-four-hour  secretion  be  charted.  At  the  earliest  intimation  that  the 
kidney  function  is  partly  suppressed  this  fact  should  be  drawn  to  the 
surgeon's  attention.  A  total  amount  of  urine  of  less  than  ten  ounces  the 
second  day  must  not  be  ignored.     Again  the  effect  of  the  operation,  the 


214  SURGICAL   NURSING 

anesthetic,  and  the  confinement  in  bed  may  cause  the  patient  to  be  unable 
to  void  the  urine  and  be  the  cause  for  bladder  retention.  The  first  step 
to  be  taken  in  all  instances  of  suppression  is  to  first  catheterize  the  bladder 
so  as  to  be  certain  that  it  is  not  a  case  of  retention  in  place  of  suppression. 
It  has  undoubtedly  been  impressed  upon  you  in  your  training  that  the 
bladder  may  be  fully  distended  and  the  patient  only  be  able  to  void  a  few 
ounces  voluntarily.  A  catheter  will  frequently  clear  up  these  cases  and 
reveal  retention  and  not  suppression  of  urine, 

POST -OPERATIVE  NURSING 

The  nurse's  chart  should  reveal  an  intelligent  record  of  the  exact  con- 
dition of  the  patient  during  the  period  of  his  convalescence.  The  pulse 
must  be  taken  and  its  rate  recorded  frequently  with  a  word  or  two  in 
explanation  of  its  character  during  the  first  twenty-four  hours.  The 
temperature  and  rate  of  respirations  are  to  be  taken  every  three  hours — • 
oftener  if  conditions  warrant — and  intelligently  recorded.  Soon  after 
regaining  consciousness  the  patient  will  complain  of  dryness  in  the  mouth 
and  ask  for  water.  As  a  rule,  it  will  be  best  to  refuse  to  give  him  a  drink. 
The  patient  should  be  assured  that  if  he  will  try  and  sleep  for  an  hour  or 
two  he  will  then  be  permitted  to  quench  his  thirst.  Unless  she  is  in 
possession  of  orders  to  the  contrary,  water  may  be  administered  in  one  or 
two  hours  after  the  operation.  The  quantity  is  gradually  increased  as 
the  tolerance  of  the  stomach  warrants.  Under  no  condition  should  any 
nourishment  be  given  until  it  is  ordered  by  the  surgeon — this  injunction 
should  hold  true  in  all  operations  upon  the  stomach  or  intestines.  During 
the  first  twenty-four  or  forty-eight  hours  all  medication  required  is  ad- 
ministered by  means  of  hypodermic  injections.  By  the  second  day  the 
nurse  will  customarily  be  ordered  to  give  the  patient  liquid  nourishment 
and  this  will  be  gradually  increased  to  soft  and  to  light  diet  before  the  end 
of  a  week. 

For  the  relief  of  gas  pains  and  for  the  securing  of  bowel  movement  after 
the  second  or  third  day  an  enema  of  salts  and  glycerin  will  be  ordered. 
Gas  pains  may  be  relieved  during  the  first  few  days  by  the  insertion  of  a 
rectal  tube,  altering  the  position  of  the  patient,  and  the  giving  of  hot 
drinks. 


OPERATION   FOR   APPENDICITIS  215 

Frequent  alcohol  rubs  will  do  much  to  overcome  the  backache 
and  muscle  pains;  these  will  also  have  a  tendency  to  rest  the  patient  and 
thereby  cause  him  to  fall  asleep. 

As  a  rule,  when  two  days  have  elapsed  the  patient  will  be  in  a  fairly 
comfortable  condition  and  he  will  require  only  general  care.  He  will  be 
permitted  to  sit  up  with  a  back  rest  on  the  fourth  or  fifth  day  and  in  a 
chair  at  the  expiration  of  a  week  or  at  the  latest  ten  days. 

In  the  event  that  the  condition  of  the  appendix  was  such  as  to  require 
the  employment  of  drainage  the  nurse  will  then  have  added  duties  to 
perform.  It  will  be  expected  that  she  keep  careful  watch  of  the  dressings 
and  when  they  become  badly  soiled  change  them,  if  so  ordered.  When 
changing  dressings  it  is  well  to  observe  the  nature  and  estimate  the  amount 
of  the  discharge  and  to  chart  these  findings.  These  dressings  will  be 
required  two  or  three  times  during  the  first  twenty-four  hours  and  twice 
a  day  thereafter.  The  drainage  most  frequently  used  is  a  perforated  or 
split  rubber  tube  surrounded  with  packing  gauze.  The  packing  gauze  is 
customarily  removed  as  soon  as  it  loosens,  usually  in  four  or  five  days; 
the  tube  is  maintained  until  the  discharge  lessens  and  becomes  more 
serous  in  character;  after  that  a  little  gauze  or  rubber  dam  is  used  to  drain 
the  wound  which  heals  by  granulations  in  from  two  to  six  weeks. 

In  all  cases  in  which  drainage  has  been  employed  the  nurse  must  be 
conscious  of  the  possibility  of  delayed  hemorrhage  by  reason  of  sloughing 
blood  vessels  or  by  pressure  necrosis  of  the  rubber  tube,  thus  causing  a 
vessel  to  rupture.  This  complication  may  occur  anywhere  from  the  fourth 
to  the  twenty-first  day  or  as  long  as  the  tube  is  in  place.  The  hemorrhage 
may  only  be  slight  or  very  severe,  depending  upon  the  vessel  that  has 
ruptured.  When  marked  and  active  the  patient  cannot  always  be  per- 
mitted to  await  the  arrival  of  the  surgeon  to  attend  to  controlhng  the 
bleeding,  for  he  is  in  danger  of  becoming  exsanguinated.  In  the  event 
then  of  an  active  secondary  hemorrhage  from  the  wound,  the  nurse  must 
seek  to  control  it.  This  is  best  done  by  firmly  packing  the  w^ound  with 
gauze  and  covering  this  with  a  pad  held  in  place  by  a  firm  binder.  When 
the  patient  loses  considerable  blood  before  the  hemorrhage  is  controlled 
and  demonstrates  the  effect  by  his  general  condition  it  is  good  treatment 


2l6  SURGICAL   NURSING 

to  administer  a  small  dose  of  morphin;  elevate  the  foot  of  the  bed;  give  a 
rectal  or  subcutaneous  normal  saline.  If  necessary,  heart  stimulants  may 
be  administered  but  one  must  necessarily  be  careful  and  avoid  overstimu- 
lation.    The  surgeon  will  advise  further  treatment. 

The  nursing  details  cannot  be  definitely  outlined  in  each  case.  It 
devolves  upon  the  nurse  to  observe  general  principles  and  adapt  them  to 
her  individual  patient.  The  minor  details  that  are  observed  all  tend  to 
add  to  the  comfort  of  the  patient  and  their  sum  total  relieves  him  of  much 
discomfort  and  annoyance  as  well  as  mental  worry.  Your  familiarity 
with  the  course  and  progress  of  post-operative  cases  and  the  observance 
of  the  principles  of  surgical  nursing  added  to  the  work  of  the  surgeon  are 
the  essential  factors  that  will  lower  the  operative  mortality.  By  the 
conscientious  performance  of  your  duty  and  the  exercising  of  similar 
judgment  and  work  on  the  part  of  the  surgeon  we  will  be  permitted  to 
say  to  the  public  that  with  the  means  now  at  their  disposal  every  death 
from  appendicitis  may  be  prevented.  Its  mortality  rate  should  be  nil; 
if  it  is  not,  then  someone  has  erred — either  the  patient  by  failing  to  consult 
a  surgeon  promptly,  or  refusing  operation;  the  surgeon  in  failing  to  operate 
in  the  early  stages;  or  the  nurse  in  committing  an  error  in  nursing  care  and 
technique.  You  will  be  freed  from  all  blame  if  you  are  familiar  with  and 
observe  the  duties  of  the  nurse  in  every  minute  detail.  To  demonstrate 
to  you  the  general  trend  of  these  duties  has  been  the  object  of  this  chapter; 
may  it  stimulate  you  to  secure  a  fuller  knowledge  of  your  duties  as  a  nurse 
in  caring  for  a  patient  submitting  to  an  operation  for  the  removal  of  the 
appendix  vermiformis,  or  for  any  operation  to  which  you  may  be  called 
to  serve  in  a  professional  capacity. 


CHAPTER  XIX 
HOSPITAL  METHODS 
SURGEON'S  FACE  MASK 

Many  surgeons  prefer  a  face  mask  that  covers  the  entire  face  (except 
the  eyes)  and  head.  The  nose  is  safeguarded  by  such  a  mask,  and  no 
nurse  need  give  any  thought  or  time  to  removing  the  perspiration  from 
the  surgeon's  face  during  the  operation. 


J 


Fig.  155. — Surgeon's  Face  Mask. 


The  pattern  here  given  is  for  a  mask  of  medium  size.  It  is  eas\^  to 
cut  the  mask  larger  if  too  small  to  be  comfortable.  The  width  of  the  mask 
(from  B  to  B)  is  twenty-five  and  one-half  inches.     The  extreme  height  is 


217 


2l8 


SURGICAL   NURSING 


twelve  and  one-half  inches.     All  other  measurements  are  given  on  the 
pattern. 

Make  of  two  thicknesses  of  cloth.  To  cut,  fold  the  pattern  and  cloth 
up  arid  down  through  the  center;  when  folded  it  will  be  seen  that  the  two 
sides  are  exactly  the  same.  Place  the  lower  edge  of  the  pattern  straight 
with  a  thread  of  the  goods.  This  will  bring  the  back  edges  of  the  mask  on 
the  bias.     Sew  the  top  of  the  mask  in  a  seam  from  A  to  B,  turn  in  the  edges 


Fig.  156. — Pattern  for  Face  Mask. 

of  the  space  for  the  eyes,  and  stitch  around  the  space  indicated  by  A-C-A. 
Hem  the  back  of  the  mask  on  both  sides  from  B  to  D.  Then  complete 
by  making  a  half -inch  hem  across  the  entire  bottom  (D  to  D)  for  a  draw 
string.  Insert  the  draw  string  and  gather  the  mask  slightly  under  the 
chin,  fastening  the  gathers  to  the  draw  string.  When  the  string  is  tied  at 
the  back  of  the  neck  the  mask  will  fit  closely  under  the  chin  and  around 
the  neck. 


HOSPITAL   METHODS 


219 


THE  MORNING  BATH 


Fig.  157. — Ready  to  Begin  the  Bath,  Showing  the  Articles  Required. 


K>\. 


Fig.  158. — Remove  the  Spread,  Cover  the  Bed  wini  a  Bath  Blanket,  and  Remove  the  Covers 

FROM  Underneath. 


220 


SURGICAL   NURSING 


ifc.-. 


4^ 


Fig.  159. — Remove  the  Upper  Sheet  erom  Underneath  the  Bath  Blanket. 


Fig.  160. — Remove  the  Pillow. 


HOSPITAL    METHODS 


221 


."•liU^ 


V 


Fig.  i6i. — Untie  the  Nightgown. 


Fig.  162. — Place  the  Bath  Blanket  under  the  Patient. 


222 


SURGICAL   NURSING 


Fig.  163. — Place  a  Bath  Towel  under  the       Fig.    164. — Place    a    Bath    Towel    over  the 
PIead.  Chest  before  Washing  the  Face. 


Fig.  165, — Wash  the  Face. 


Fig.  166. — Cleanse  the  Teeth. 


HOSPITAL   METHODS 


225 


Fig.  167. — Expose  the  Arm. 


Fig.  168. — Wash  the  Arm,  after  Placing  a  Bath  Towel  Underneath. 


224 


SURGICAL  NURSING 


wrr 


/ 


^.^    V    /-H- 


Fig.  169. — Wash  the  Hand. 


jryvf 


K^ 


/ 


(■-^ 


Fig.  170. — Manicure  the  Nails. 


HOSPITAL   METHODS 


22 


Fig.  171. — Bathe  the   Chest.     Note  Protection  of   Bedding  with  Bath  Towel. 


Fig.  172. — Turn  the  Patient  on  His  Side  and  Bathe  the  Back. 


IS 


226 


SURGICAL   NURSING 


^1 


Fig.  173. — Bathe  the  Abdomen. 


Fig.  174. — Place  a  Bath  Towel  under  the  Leg. 


HOSPITAL   METHODS 


227 


\ 


^I^R^- 


/ 


V.46— »   a»: 


iL'; 


Fig.  175. — Bathe  the  Leg. 


.A 


Fig.  176. — Place  a  Rubber  Sheet  and  Bath      Fig,   177. — Pkotect    the    Edge    op    the    Tub 
Towel  under  the  Feet.  with  a  Towel. 


228 


SURGICAL   NURSING 


.  i 


V 


-^-T^- 


Fig.  178. — Bathe  the  Feet. 


Fig.  179 — Remove  the  Feet  from  the  Txm. 


^■■ 


.»j     r 


^ 


Fig.  180. — Wrap  the  Feet  in  a  Bath  Towel 
AND  Remove  the  Tub. 


Fig.  181. — Cleanse  the  Toe  Nails. 


HOSPITAL   METHODS 


229 


i 


/ 


>  /3 


ii^' 


.^ 


J 


Figs.  182  and  183. — Remove  the  Towel  and  Rubber  Sheet,  after  Which  the  Patient  is 
Covered  with  a  Dry  Blanket  and  the  Bed  Made. 


BEDMAKING 


b- 


Fig,  184. — Grasp  the  Bath  Blanket  Underneath  the  Dry  Blanket  Which  was  Thrown 
over  the  Patient  at  the  Conclusion  of  the  Bath. 


230 


SURGICAL   NURSING 


Fig.  185. — Remove  the  Bath  Blanket. 


:^\ 


ViG.  i<S6. — Turn  the  Patient  ox  JIis  Side  and  Fold  Back  the  Top  Blanket. 


HOSPITAL   METHODS 


231 


Fig.  187. — Roll  Back  the  Blanket  from  Beneath  the  Patient. 


Fig.  188. — Roll  the  Patient  toward  You  and  Remove  the  Blanket  Which  was  Underneath. 


232 


SURGICAL   NURSING 


#»„ 


Fig.  189. — Turn  the  Patient  and  Roll  the  Under  Covers  against  His  Back. 


SHHk_^ 


t': 


*   wmwmm 


MM^m. 


Fig.  190. — Brush  the  Mattress. 


HOSPITAL   MEIHODS 


233 


Fig.  191. — Ri.PLACE  the  Mattress  Pad  and  Stretch  it  Smooth  to  Avoid  Wrinkles. 


Fig,  192. — Brush  the  Mattress  Pad. 


234 


SURGICAL   NURSING 


Fig.  193. — Draw  the  Sheet  Tight. 


■^'Mm 


Fig.  194. — Brush  the  Sheet. 


HOSPITAL   METHODS 


235 


Fig.  195. — Replace  the  Rubber  Sheet. 


Fig.  196. — Draw  the  Rubber  Sheet  Tight. 


236 


SURGICAL   NURSING 


Fig.  197. — Brush  the  Rubber  Sheet. 


C^^^  ^    -  ^  ^. , -"* 


Fig.  108. — Unroll  the  Drawsheet. 


HOSPIIAL   METHODS 


237 


Fig.  iqq. — Draw  the  Drawsheet  Tight. 


Fig.  200. — Brush  the  Drawsheet. 


238 


SURGICAL   NURSING 


Fig.  201". — ^Spread  the  Clean  Upper  Sheet. 


.^"^^ 


Fig.  202. — Remove  the  Dry  Bath  Blanket  from  Underneath  the  Clean  Sheet. 


HOSPITAL   METHODS 


239 


7  ^ 


mt'^^i 


Fig.  203. — The  Upper  Blanket  in  Place  and  Tucked  in. 


Fig.  204.— Draw  the  Patient's  Hand  into  the  Sleeve  of  the  Clean  Nightgown. 


240 


SURGICAL   NURSINC 


Fig.  205. — Draw  on  the  Sleeve  and  Put  on  the  Gown. 


'^ta 


Fig.  206. — Comb  the  Patient's  Hair. 


HOSPITAL   METHODS 


241 


Fig.  207. — Put  on  the  Spread  and  Replace  the  Pillow,  thus  Completing  the  Moening 

Bath  and  Bedmaking. 


THE  SLUSH  BATH 


■4 

I 


Fig.  208. — Articles  required:  Two  blanket  rolls,  each  roll  consisting  of  two  blankets,  to  form  the 
sides  of  the  tub  (when  in  place,  the  rolls  are  tied  with  a  bandage  at  each  end  and  in  the  middle  to 
prevent  unrolling;  see  Fig.  211);  two  flannel  blankets;  two  sheets;  one  large  rubber  sheet;  towels 
pitcher;  bath  pan  or  bowl;  foot  tub;  ice  cap;  bandages;  bed  elevators. 


16 


242 


SURGICAL   NURSING 


Fig.  209. — Upper  bedding  removed,  patient  covered  with  bath  blanket  and  rolled  to  side  of  bed. 
Rolled  at  the  patient's  back  are  first  a  blanket,  next,  the  rubber  sheet,  and  over  this  a  sheet. 


Fig.  210. — The  bedding  to  protect  the  mattress  unrolled  close  to  the  patient.  The  latter  will 
now  be  rolled  toward  the  opposite  side  of  the  bed  to  permit  the  nurse  to  unroll  the  protective  covers 
in  one  movement. 


HOSPITAL   METHODS 


243 


Fig.  211. — The  blanket,  rubber  sheet,  and  sheet  have  been  folded  over  the  patient,  who  has  been 
turned  back  to  the  center  of  the  bed,  and  the  blanket  rolls  have  been  placed  at  the  patient's  sides  and 
tied  with  bandages  to  hold  the  rolls  in  place. 


244 


SURGICAL   NURSING 


Fig.  212. — The  rubber  sheet,  blanket,  and  sheet  have  been  unfolded  and  carried  over  the  roll 
on  each  side,  forming  a  trough  in  which  the  patient  lies.  A  pillow  has  been  placed  under  the  patient's 
head,  protected  by  rubber  sheeting,  and  the  head  of  the  bed  has  been  elevated.  An  ice  cap  and  cold 
compress  are  at  the  patient's  head,  and  a  hot-water  bottle  at  his  feet.  Cold  compresses  are  in  place 
in  the  axillae. 


HOSPITAL   METHODS 


245 


Fig.   213, — The  nurse  is  pinning  tlie  edges  of   the   rubber   sheeting   together   to   form   an   outlet 

through  which  the  water  may  flow. 


246 


SURGICAL   NURSING 


Fig.  214. — To  begin  the  bath,  the  nurse  soaks  a  sea  sponge  or  large  bath  cloth  in  the  bath  water. 


HOSPITAL   METHODS 


247 


W0^ 


■MHr 


Fig.  215. — In  giving  the  bath,  the  nurse  flows  or  slushes  water  over  the  entire  body,  allowing  the 
water  to  fall  from  a  height  of  10  to  14  inches  above  the  body  surface,  over  all  parts  of  which  she 
continues  to  slowly  carry  the  sponge. 


248 


SURGICAL  NURSING 


Fig.  2 1 6. — After  continuing  the  batli  tlie  time  prescribed,  the  sheet,  rubber  sheet,  rolls,  and 
blanket  are  removed  and  the  patient  is  wrapped  in  the  bath  blanket  which  was  underneath.  The 
ice  cap  and  hot-water  bottle  remain  in  place.  The  under  sheet  has  not  been  disturbed  or  saturated 
in  giving  the  bath. 

.  TUB  BATH  IN  BED 


_(5>i!  >•%*,;;? 


##4 


Fig.  217. — The  nurse  is  unrolling  the  flannel  blanket,  rubber  sheet,  and  sheet  which. had  been 
placed  at  the  patient's  back  as  shown  in  Fig.  209  of  the  Slush  Bath. 


HOSPITAL   METHODS 


249 


Fig.  218. — The  patient  has  been  rolled  to  the  center  of  the  bed,  and  the  blanket,  rubber  sheet, 
and  sheet  thrown  over  him,  while  the  rolls  have  been  placed  at  the  sides  of  the  bed.  These  rolls  are 
kept  in  position  by  bandages  carried  both  under  the  patient  and  under  the  bed. 


Fig.  219. —  Side  view  of  the  improvised  tub.  An  ice  cap  and  a  cold  compress  have  been  placed 
at  the  patient  s  head,  and  cold  compresses  in  the  axilte.  The  sheet  between  the  patient  and  the 
rubber  sheet  is  tucked  in  between  the  sides  of  the  patient  and  the  rolls  which  constitute  the  sides  of 
the  tub. 


250 


SURGICAL   NURSING 


Fig.  220. — The  tub  has  been  completed,  the  head  being  formed  by  pillows  and  the  foot  by  a 
third  blanket  roll,  and  all  covered  by  a  rubber  sheet.  The  result  is  a  complete  tub  capable  of  holding 
8  to  10  inches  of  water. 


m^^ 


Fig.   221. — While  water  is  being  poured  over  the  patient  an  assistant  maintains  constant  stroking 

over  the  surface  of  the  body. 


HOSPITAL   METHODS 


251 


Fig.  222. — The  water  may  be  poured  from  a  pitcher  instead  of  using  a  bath  sponge  or  a  doth. 


Fig.   223. — After  filling  the  tub  to  the  point  of  safety,  the  patient  is  rubbed  during  the  period  for 

which  the  bath  has  been  prescribed 
At  the  completion  of  the  bath,  the  tub  is  drained  from  the  foot  as  in  the  slush  bath,  the  sheet, 
rubber  sheet,  rolls,   and  blanket  are  removed,  and  the  patient  wrapped  as  shown  in  Fig.   216  on 
page  248. 


2^2 


SURGICAL   NURSING 
HYPODERMOCLYSIS 


Fig.  224. — Supplies  Required  for  Hypodermoclysis  Arranged  within  Easy  Reach  of 

THE  Operator. 
The  articles  are  as  follows:  Two  sterile  enameled  pitchers  in  sterile  containers;  two  flasks  of 
saline  solution;  tincture  of  iodin;  bath  thermometer  in  sterile  solution;  two  sterile  basins,  one  over 
the  other,  containing  rubber  tubing,  needles,  and  flask  cork  and  bulb;  saline  graduate  (sterile)  in 
sterile  container;  one  package  of  sterile  towels;  one  package  of  sterile  gauze;  alcohol;  bichlorid, 
i-iooo;  green  soap;  collodion. 


Fig.  225, — The  Supplies  with  Covers  Removed,  Open  and  Ready  for  Use. 


HOSPITAL   METHODS 


253 


Fig.  226. — The  Field   of   Operation   Exposed,   Showing  Arrangement  of  Nightgown 

AND  Bedding. 


Fig.  227. — ScRUBBED-up  Nurse  Taking  Sterile  Towels  from  Package  Which  is  being  Handed 

Her  by  the  Unscrubbed  Nurse. 


2  54 


SURGICAL   NURSING 


Fig.  228. — Unscriibbed  Nurse  Pouring  Sterile  Water  and  Green  Soap  on  Sterile  Gauze, 
WITH  Which  the  Sterile  Nurse  is  to  Scrub  the  Site  or  the  Needle  Insertion. 


Fig,  229.— Sterile  Nurse  Scrubbing  Site  or  Injection. 


HOSPITAL   METHODS 


255 


Fig.  230. — Unscrubbed  Nurse  Pouring  Bichlorid  on  Sterile  Gauze   for   Second    Step 

or  Sterilizing  the  Field. 


Fig.  231. — Cleansing  the  Site  with  Alcohol  to  Complete  Sterilization  of  the  Field. 


256 


SURGICAL   NURSING 


Fig.  232. — Assisting  Nurse  Pouring  Iodin  upon  Gauze  with  Which  the  Surgeon  will 

Complete  the  Sterilization  of  the  Field. 

Some  operators  use  iodin  only  and  omit  the  alcohol  and  bichlorid. 


Fig.  233. — Application  of  Iodin  by  Surgeon  to  the  Site  of  Injection. 


HOSPITAL    METHODS 


257 


Fig.  234. — The  Site  of  the  Injection  Covered  with  Sterile  Gauze   and  the   Chest 

Draped  with  Sterile  Towels. 


Fig-  235. — Sterile  Nurse  Taking  the  Graduate  Container  from  its  Wrapping  AA'hich 

IS  Held  by  the  Assisting  Nurse. 
17 


258 


SURGICAL   NURSING 


Fig.  236. — Sterile  Nurse  Removing  the  Sterilized  Rxibber  Tubing,  Bulb,  and  Needles  from 
THE  Sterile  Basin  in  Which  They  have  been  Sterilized. 


Fig.  237. — Sterile  Nurse  Attaching  the  Sterile  Rubber  Tubing  to  the  Saline  Graduate. 
The  tubing  has  been  placed  upon  the  sterile  drape  towel.     The  assisting  nurse  has  the  pitcher  of 
sterile  saline  solution  ready  to  pour  into  the  saline  graduate.     The  saline  solution  should  be  110° 
when  poured  into  the  saline  graduate.     Before  injected  it  will  have  cooled  several  degrees. 


HOSPITAL   METHODS 


259 


Fig.  238. — Sterile  Nurse  Placing  the  Stopper  and  Bulb  in  the  Saline  Graduate  That  has 

BEEN  Filled  with  tjee  Saline  Solution. 

The  tube  is  clamped  to  prevent  flow  of  the  solution. 


"51 


^K 


Fig.  239. — Sterile  Nurse  Handing  the  Tubes  and  Needles  to  the  Surgeon. 
By  this  method  neither  the  nurse  nor  surgeon  touches  the  needles. 


26o 


SURGICAL   NURSING 


Fig.  240. — Sterile  Nue.se  Removing  the  Sterile  Gauze  from  the  Cleansed  Site  of  the 
Injection,  and  the  Surgeon  Ready  to  Insert  the  Needles. 


Fig.  241. — Injection  of  the  Saline  Solution. 
The  nurse  is  gradually  forcing  the  saline  out  of  the  graduate  by  compressing  the  bulb.     From 
400  to  800  cc.  may  be  injected  during  a  single  procedure.      During  the  injection  the  fluid  is  dis- 
seminated under  the  breast  by  gentle  rotary  massage. 


HOSPITAL   METHODS 


261 


Fig.  242. — The  Injection  Completed. 

The  assisting  nurse  is  pouring  collodion  on  two  pledgets  of  sterile  cotton  held  by  the  sterile  nurse 

to  seal  the  punctures  made  by  the  needles. 


Fig.  243. — Application  of  Pledgets  of  Cotton  Saturated  with  Collodion  over  the  Punctitre 
Sites  before  Withdrawing  the  Needles. 


262 


SURGICAL   NURSING 
THE  TECHNIC  OF  THYROIDECTOMY 


Fig.  244. — Patient 
ON  Operating  Table. 
Anesthetic  Com- 
menced. Field 
Draped  with  Ster- 
ilized Towels  Pre- 
paratory TO  Ster- 
ilization OF  the  Site. 

Note  nurse  read}' 
to  paint  the  field  with 
benzin-iodin  solution. 
She  holds  two  sterile 
sjionges,  rolled,  and  a 
small  cup  of  the  solu- 
tion in  her  left  hand. 
Observe  the  method 
of  draping  towels 
around  the  field  of 
operation.  Notice 
that  the  patient's  hair 
is  covered  with  a  rub- 
ber cap. 


Fig.  24S.^Nurse 
Sterilizing  the  Field 
OF  Operation  with 
Benzin-iodin  Solu- 
tion. 

The  prepared  area 
extends  from  the  chin 
and  jaw  to  three  inches 
below  the  clavicle  and 
well  back  of  the  shoul- 
ders. Note  approved 
operating  uniform  and 
headgear  worn  by  the 
surgical  nurse. 


HOSPITAL    METHODS 


263 


-^ 


Fig.  246. — Ready  foe  the  Operation. 
Sterile  sheets  and  towels  are  held  in  place  with  towel  clamps. 


Fig.  247. — First  Incision  through  the  Skin. 

Artery  forceps  clamped  on  a  superficial  blood  vessel.     This  view  shows  the  complete  isolation  of 

the  anesthetist  and  the  patient's  face  from  the  operative  wound  by  the  sterile  screen. 


264 


SURGICAL   NURSING 


Fig.  248. — Delivering  the  Right  Lobe  of  the  Thyroid. 
Although  thyroidectomy  is  a  bloody  operation,  it  wUl  be  observed  that  loss  of  blood  has  been 
controlled  by  prompt  hemostasis  and  the  draped  field  thus  far  kept  clean.     The  assistant  is  ready 
with  opened  artery  forceps  to  immediately  clamp  a  "bleeder"  and  is  sponging  with  his  left  hand. 


Fig    249. — ^LoBE  op  Gland  Removed. 
Note  the  large  number  of  artery  snaps  necessary  to  control  the  hemorrhage. 


HOSPITAL    METHODS 


265 


Fig.  250. — The  Incision  has  been  Sutured  with  a  Subcutaneous  Suture  and  is  Ready 

FOR  THE  Dressing. 


Fig.  251. — The  First  Dressing  in  Place. 
Observe  that  the  field  is  kept  clean  by  replacing  the  soiled  towels  with  sterile  ones. 


266 


SURGICAL   NURSING 


Fig.  252. — Gauze  Dressings  in  Place,  Ready  to  be  Covered  with  Sterile  Cotton. 
Note  the  abundance  of  dressings  employed. 


Fig.  253. — Gauze  Dressings  Covered  with  Sterile  Cotton. 
The  wound  dressing  is  now  ready  for  the  bandage. 


HOSPITAL    METHODS 


267 


-mjpmp-: 


Fig.  254. — Dressing  Completed. 
The  roller  bandage  over  the  cotton  and  gauze  dressings  is  carried  around  the  neck,  under  the  arms, 

and  around  the  chest. 


-^^■-^ 


Fig.  255. — Administration  of  Oxygen  during  the  Oper.ation. 


INDEX 


Abdominal  dressings,  87 
preparing  for,  113 
muscles,  relieving  tension  on,  in  bed,  97 
pad,  87 

held  by  adhesive  tape,  88 
tapes,  untying,  114 
Adhesive  tape,  abdominal  pad  held  by,  88 
Alcohol  as  disinfectant,  165 
Alcohol-sublimate  method  of  hand  sterilization, 

48 
Amputations,  breast,  dressings  of,  89 
major,  dressings  of,  89 
nursing  after,  97 
Anesthesia,  151 
chloroform,  152 
choice  of,  154 
distress  after,  155 
duties  of  nurse  during,  154 
ether,  152 
local,  153 

nitrous  oxide-gas,  152 
novocain,  153 

scopolamin  and  morphin,  153 
spinal,  153 
Anesthetist,  duties  of,  73 

table  for,  28 
Antibodies,  action  of,  39 

Antiseptic  solutions  for  sterilization  of  instru- 
ments, 34 
Antiseptics,  chemical,  165 

used  in  hand  sterilization,  46 
Anuria,  acute,  post-operative,  130 
Appendectomy  scar,  satisfactory,  139 
Appendicitis,  acute,  symptoms,  203 
cause,  202 
complications,  204 
definition,  202 
McBurney's  point  in,  203 
nature  of  disease,  202 
operation  for,  202,  204 

care  of  patient  after,  210,  214 

of  wound  after,  211 
complications,  211 
distention  after,  212 
duties  of  sterile  nurse,  207-210 

of  unsterile  nurse,  207 
gas  pains  after,  212 


Appendicitis,   operation    for,    kidney    secretion 
after,  213 

nurse's  duties,  202 

pre-operative  duties,  205 

preparation  of  patient,  204 
of  room,  205 

setting-up,  206 

shock  after,  211 

temperature  after,  213 

unpacking  kit,  206 

vomiang  after,  211 

water-supply  for,  206 

what  to  watch  for  after,  211 
Applications,  temperatures  of  water  for,  168 

Back,  wounds  of,  dressings  of,  89 
Back-ache,  post-operative  prevention  and  treat- 
ment, 96 
Bacteria,  common  forms,  in  septic  infection,  39 
Bandage,  many-tailed,  in  position,  70 
Bath  before  operation,  61 

morning,  219-229 

slush,  241-248 

temperatures  of  water  for,  168 

tub,  in  bed,  248-251 
Bed,  elevation  of  foot,  after  operation,  95 
of  head,  after  operation,  94 

posture   for   relieving   tension   on   abdominal 
muscles,  97 

preparation  of,  after  operation,  91-95 

tub  bath  in,  248-251 
Bed  making,  229-241 

Bench,  improvised,  for  hand  sterilization,  34 
Benzin  for  sterilization  of  operative  field,  65 
Bichlorid  of  mercury  as  disinfectant,  166 

in  hand  sterilization,  47 
Binder,  scultetus,  89 
Block,  salt,  85 

Boric  acid  as  disinfectant,  166 
Bowels,  care  of,  before  operation,  60 

movements  of,  recording,  158 
Brain  operations,  position  for,  68 
Breast  amputations,  dressings  of,  89 

position  for,  68 
Burns,  hot- water  bottle,  prevention  of,  92 


Carbolic  acid  as  disinfectant,  166 


269 


270 


INDEX 


Cardiac  collapse,  post-operative,  126 
causeS;  126 
symptoms,  126 
treatment,  127 
exhaustion  of  second  period,  127 
causes,  127 
symptoms,  127 
treatment,  128 
Carminative  enema,  169 
Cast,    plaster-of-Paris,    183.     See    also   Plaster- 

of-Paris  splint. 
Catgut  in  glass  tubes,  preparing,  171 

preparation  of  Willard  Bartlett  method.,  171 
sutures,  sizes,  82 
Cathartics  after  operation,  in 
Catheter,  sterilization  of,  198 
Catheterization,  198 

after  operation,  loi,  112 
comments  on,  201 
dangers  to  avoid,  198 
equipment  for,  199 

method  of,  199  _  " 

sterilization  of  hands  before,  199 
tray  for,  112 
Changing  dressings,  144-148 
preparations  for,  149 
preparing  patient  for,  149 
recording  of,  149 
requirements  for,  143 
Chart  record,  nurse's,  156 
after  operation,  106 
Chemical  antiseptics,  165 

disinfectants,  165 
Chest,  dressings  of,  89 
Chlorinated  hme  as  disinfectant,  166 
Chloroform  anesthesia,  152 
Cigarette  drain,  86 
Clean  nurse,  29 
Cleansing  wounds,  141 
Clothing,  method  of  disinfecting,  167 

proper,  for  operating  room,  43 
Coagulation  fibrin  in  wounds,  138 
Codein  after  operation,  loi 
Collapse,  cardiac,  post-operative,  126 
causes,  126 
symptoms,  126 
treatment,  127 
post-operative,    125.     See   also  Post-operative 
collapse. 
Consciousness,  returning,  care  of  patient  in,  97 
Continuous  suture,  80 
Conversation  during  operation,  76 
Corrosive  cotton,  preparation  of,  177 
Cotton  gloves,  sterile,  use  of,  57 


Dakin's  solution,  preparation  of,  177 
Dam,  rubber,  preparing,  172 
Days,  post-operative,  recording,  163 
Delayed  hemorrhage,  post-operative,  128 
Delirium  control  of,  96 
Demeanor  of  nurse  during  operation,  76 
Dilatation,  acute  gastric,  post-operative,  129 
symptoms,  129 
treatment,  130 
Dining  table,  arrangement  of,  for  Trendelenburg 

position,  27 
Disinfectants,  chemical,  165, 
Disinfection,  methods  of,  167 
Distention  after  operation  for  appendicitis,  212 
Distress  after  anesthesia,  155 
Douches,  temperatures  of  water  for,  168 
Drainage  material,  preventing  loss  of,  in  wounds, 

142 
Draining  wounds,  141 

dressing,  141 
Drains,  84 
cigarette,  86 
gauze,  84,  85 
rubber,  86 
silkworm-gut,  80 
Draping  of  operative  field,  66 
Dressing  draining  wounds,  141 
infected  wounds,  116 
wounds,  141 
Dressings,  87 
abdominal,  87 

preparing  for,  113 
after  operation,  113 
changing,  144-148 
preparations  for,  149 
preparing  patient  for,  149 
recording  of,  149 
requirements  for,  145 
first,  88 
gauze,  87 

preparation  of,  176 
recording,  162  • 

soiled,  disposal  of,  149 
Dusting  powders  for  wounds,  140 


Elevation  of  foot  of  bed,  95 

of  head  of  bed  after  operation,  94 

Emergencies,  post-operative,  120 

Enemata,  classification,  168 
temperatures  of  water  for,  168 

Ether  anesthesia,  152 

Everting  suture,  80 

Excretions,  recording,  158 


INDEX 


271 


Exhaustion  cardiac,  of  second  period    127 

causes,  127 

symptoms,  127 

treatment,  128 
pos' -operative,  131 
Extremities,  dressings  of,  89 
Exuberant  granulation  in  wounds,  138 
Eye,  dressing  of  89 

Face,  dressings  of,  89 

Face  masli,  surgeon's,  21 

Failure,  respiratory,  post-operative.  126 

causes,  125 

s3'mptoms,  126 

treatment,  126 
Feces,  method  of  disinfecting,  167 
Fibrin,  coagulation,  in  wounds,  138 
Fibrous  tissue,  formation  of,  in  wounds,  137 
First  assistant  to  surgeon,  duties,  72 
dressings,  88 

intention,  healing  of  wounds  by,  136 
Flatus  after  operation,  no 

treatment,  in 
Flaxseed  enema,  170 

poultice,  165 
Flesh,  proud,  138 
Foot  of  bed,  elevation  of,  95 
Formalin  as  disinfectant,  167 
Formulae,  165 
Fowler's  position,  95 
Fractional  sterilization  of  normal  saline  solution, 

26 
Friends,  attitude  toward,  after  operation,  106 
Fumigation  of  private-house  operating  room,  24 

Gall-bladder  operation,  position  for,  68 
Gas  pains  after  operation  for  appendicitis,  212 
Gastric  dilatation,  acute,  post-operative,  129 
symptoms,  129 
treatment,  130 
Gastric  lavage  after  operation,  98,  99 
Gauze,  cutting,  for  plaster-of-Paris  splint,  186, 
187 
drain,  84,  85 
dressings,  87 

preparation  of,  173-176 
impregnating  with  plaster  in  making  plaster- 
of-Paris  splint,  190 
method  of  sterilizing,  167 
packing,  preparation  of,  176 
pads,  plain,  preparation  of,  176 
sponges,  84 

keeping  account  of,  82 
uses  of,  84 


Getting  up  after  operation,  117 
Glover's  suture,  80 
Gloves,  rubber,  preparing,  51-57,  172 
sterile,  changing,  57 
sterile  cotton,  use  of,  57 
Glycerin  enema,  168 
Goiter  operation,  position  for,  68 

preparation  for,  69 
Gown  for  surgeon,  43 

method  of  putting  on,  b}'  sterile  nurse,  49 
preparation  of,  175 
Granulation  of  wounds,  exuberant,  138 
healing  by,  137 
stimulation  of,  142 

Hagedorn  saber-pointed  needle  in  holder,  78 
Hand  sterilization,  38 

alcohol-sublimate  method,  48 

antiseptics  used,  46 

applying  iodin  to  nails  in,  46 

arrangement  of  improvised  bench  for,  34 

before  catheterization,  199 

bichlorid  of  mercury  in,  47 

final  process,  47 

iodin  in,  47 

Kelly- Welch  method,  48 

lysol  method,  50 

manicuring  before,  43 

materials  required  for,  45 

methods,  38,  41 

oil  of  cloves  method,  50 

precautions  of  sterile  nurse  after,  57 

scrubbing  with  soap  in,  42 

soaps  for,  42 

technique,  44,  45 

Weir-Stimson  method,  48 
Head,  dressings  of,  89 

of  bed,  elevation  of,  after  operation,  94 
Healing  of  wounds  by  iirst  intention,  136 

by  granulation,  137 

by  second  intention,  137 

by  third  intention,  138 
Hemorrhage,  post-operative,  121 

causes,  122 

delayed,  128 

prevention,  123 

symptoms,  123 

treatment,  124 
Hernia,  ventral,  in  scars,  139 
Horsehair  ligatures,  preparing,  171 
Hospital  kit,  surgeon's,  178 
contents,  179,  180 
uses,  181 
methods,  217 


272 


INDEX 


Hot- water  bottle  burns,  prevention  of,  92 
Hypersensitive  scars,  139 
Hypodermoclysis,  252-261 

Ileus,  post-operative,  129 

Improvised  operating  table,  patient  on,  67 

Incised  wounds,  136 

Infected  wounds,  dressing,  116 

treatment,  143 
Infection,  septic,  common  forms  of  bacteria  in, 

39 
methods  of  bacterial  invasion  in,  40 
of  prevention,  41 
Instrument  stand  with  instruments  arranged,  76 
Instruments,  classification  of,  by  groups,  77 
duties  of  sterile  nurse  with,  77,  79 
sterile,  table  of,  33 
sterilization  of,  33 
after  operation,  35 
antiseptic  solutions  for,  34 
water  for,  33 
Interrupted  suture,  80 
Intestinal  obstruction,  post-operative,  128 
causes,  128 
symptoms,  128 
treatment,  129 
lodin,  tincture  of,  165 

for  sterilization  of  hands,  46,  47 
of  operative  field,  65 
Iodoform  formula,  177 

Kangaroo  tendon  in  glass  tubes,  preparing,  171 
Kelly-Welch  method  of  hand  sterilization,  48 
Kidneys,  care  of,  before  operation,  61 

excretion  of,  after  operation  for  appendicitis, 
213 
recording,  158 
operation  on,  position  for,  68,  69 
Kit,  surgeon's  hospital,  178 
contents,  179,  180 
uses,  181 

Lamp,  surgeon's  portable,  20 
Laparotomy    kit    for    private    house    operating 
room,  30 

patient  prepared  for,  75 
Lavage,  gastric,  after  operation,  98,  99 
Leggings,  surgical,  62 
Lembert  sutures,  81 
Ligatures,  horsehair,  preparing,  171 
Lighting  for  private  house  operating  room,  20 
Limb,     measurement     of,     for     plaster-of-Paris 
splint,  184 

preparing  of,  for  plaster-of-Paris  splint,  191 


Lime,  chlorinated,  as  disinfectant,  166 
Linen  sutures,  preparation  of,  171 
Liquid  nourishment  after  operation,  109 
Local  anesthesia,  153 
Lysol  as  disinfectant,  167 

method  of  hand  sterilization,  50 

Manicuring  before  hand  sterilization,  43 

Many-tailed  bandage  in  position,  70 

Mask,  surgeon's  face,  217 

Massage,  danger  of,  in  phlebitis,  134 

McBurney's  point  in  appendicitis,  203 

Measurement  of  limb  for  plaster-of-Paris  splint, 

184 
Medication  after  operation,  104 

given,  recording,  163 
Mercury  bichlorid  as  disinfectant,  166 

in  hand  sterilization,  47 
Molasses  enema,  169 
Morning  bath,  219-229 
Morphin  after  operation,  loi 
Murphy  drip  after  operation,  103 
Muscles,    abdominal,    relieving    tension    on,    in 

bed,  97 
Muscular  rigidity,  in  appendicitis,  203 
Mustard  plaster,  165 

poultice,  165 

Nausea  in  appendicitis,  203 
Needle-holder,  proper  way  of  handling,  78 
with  full-curved  threaded  needle,  78 
with  Hagedorn  saber-pointed  needle,  78 
Needles,  care  of,  82 
Nitrous  oxide- gas  anesthesia,  152 
Normal  salt  solution,  167 
Nourishment  after  operation,  loi,  109 

taken,  recording,  162 
Novocain  anesthesia,  153 
Nurse,  chart  records  of,  156 

demeanor  of,  during  operation,  75 
duties  of,  after  operation,  89 
during  anesthesia,  154 
during  operation,  72 

in  appendicitis  operation,  202.     See  Appen- 
dicitis, operation  for. 
proper  clothing  for,  in  operating  room,  43 
sterile,  29 

care  of  needles,  82 

of  operative  field,  82 
duties  at  operation,  77 

in  appendicitis  operation,  207 
with  instruments,  77,  79 
in  sterile  gown  and  gloves,  41 
method  of  putting  on  gown,  49 


INDEX 


273 


Nurse,  sterile,  precautions  after  liand  steriliza- 
tion, 57 
removing  sterile  supplies  frona  package  by, 

31 
unsterile,  29 

duties,  in  appendicitis  operation,  207 
method  of  opening  unsterile  supplies,  31 
Nursing,    post-operative,    91.      See    also    Post- 
operative nursing. 
surgical,  outline  of,  18 
Nutritive  enema,  169 

method  of  administering,  169 

Obstruction,  intestinal,  post-operative,  128 
causes,  128 
symptoms,  128 
treatment,  129 
Oil  and  turpentine  enema,  169 
enema,  168 

of  cloves  method  of  hand  sterilization,  50 
Operating   room,   private   house,    20.     See   also 
Private  house  operating  room. 
proper  clothing  for,  43 
staff,  preparation  for  operation  by,  50 
table  for  private  house  operating  room,  27 
preparation,  27 
Trendelenburg  position,  27 
improvised,  patient  on,  67 
positions  of  patient  on,  67 
Operation,  care  of  patient  after,  91.     See  also 
Post-operative  nursing. 
conversation  during,  76 
demeanor  of  nurse  during,  76 
details,  recording,  163 
duties  of  nurse  during,  72 

of  sterile  nurse  at,  77 
for  appendicitis,  nurse's  duties,  202.     See  also 

Appendicitis,  operation  for. 
prepfiration  for,  by  operating  room  staff,  50 

of  bed  after,  91-9S 
vomiting  after,  treatment,  97 
Operative  field,  care  of,  82 
drapifig  of,  66 
preparation  of,  64 
sterilization  of,  65 
group,  73,  74 
Opsonins,  action  of,  39 

Packiistg,  gauze,  preparation  of,  176 
Packs,  us^s  of,  82 
Pads,  abdominal,  87 

held  by  adhesive  tape,  88 
plain  gsiuze,  preparation  of,  176 
Pagenste(jher's  linen,  preparation  of,  171 


Pain  after  operation,  treatment,  loi 

in  appendicitis,  203 
Patient,  care  of,  after  operation,  91.     See  also 
Post-operative  nursing. 
changing  position  of,  96 
observation  of,  after  operation,  99 
on  improvised  operating  table,  67 
positions  of,  on  operating  table,  67 
preparation  of,   58.     See  also   Preparation  of 
patient. 
for  night,  after  operation,  iic 
for  laparotomy,  75 
preventing  slipping  down  in  bed,  95 
recovering  from  anesthetic,  98 
toilet  of,  after  operation,  108 
Peritonitis,  post-operative,  130 
symptoms,  130 
treatment,  131 
Persistent  vomiting,  post-operative,  131 

treatment,  133 
Phlebitis,  post-operative,  133 
symptoms,  133 
treatment,  134,  135 
Plaster,  mustard,  165 
Plaster-of -Paris,  grades  of,  184 
splint,  183 

application,  194 
cutting  gauze  for,  186 
impregnating  gauze  with  plaster,  190 
making  pattern  for,  185 
measurement  of  limb  for,  184 
pattern  completed  for,  186 
points  in  making,  197 
preparing  the  limb,  191 
supplies  required  for,  183,  184 
Pneumonia,  post-operative,  131 
Portable  surgeon's  lamp,  20 
Position  for  amputation  of  breast,  68  ; 

for  operation  on  brain,  68 
on  gall-bladder,  68 
on  kidney,  68,  69 
on  skull,  68 
on  vagina,  71 
Fowler's,  95 

in  bed  to  prevent  tension  on  abdominal  mus- 
cles, 97 
of  patient  on  operating  table,  67 
Trendelenburg,  68,  70 
Post-operative  acute  anuria,  130 
gastric  dilatation,  129 
symptoms,  129 
treatment,  130 
cardiac  collapse,  126 
causes,  126 


274 


INDEX 


Post-operative  cardiac  collapse,  symptoms,  126 
treatment,  127 
complications,  sequence  of,  132 

table  of,  132 
days,  recording,  163 
emergencies,  120 
exhaustion,  131 
hemorrhage,  121 

causes,  122 

delayed,  128 

prevention,  123 

symptoms,  123 

treatment,  124 
ileus,  129 

intestinal  obstruction,  128 
causes,  128 
symptoms,  128 
treatment,  129 
nursing,  91 

administration  of  water,  100 

after  amputations,  97 

attitude  toward  friends  and  relatives,  106 

backache,  prevention  and  treatment,  96 

cathartics,  in 

catheterization,  loi,  112 

changing  position  of  patient,  96 

codein  in,  10 1 

continuous  drop  proctoclysis  in,  103 

controlling  delirium,  96 

dressings,  113 

during  first  twenty-four  hours,  91 

elevation  of  foot  of  bed,  95 
of  head  of  bed,  94 

flatus,  no 

treatment,  in 

Fowler's  position,  95 

getting  up,  117 

in  returning  consciousness,  97 

keeping  chart,  106 

liquid  nourishment  in,  109 

medication  in,  104 

morphin  in,  loi 

Murphy  drip  in,  103 

nourishment  in,  loi 

pain  in,  treatment,  loi 

preparation  of  bed,  91-95 

preparing  patient  for  night,  no 

preventing  backache,  96 
slipping  down  in  bed,  95 

prevention  of  hot- water  bottle  burns,  92 

pulse  in,  105 

restlessness,  treatment,  109 

room  requirements,  93 

salines  in,  103 


Post-operative  nursing,  soreness  from  sitting  up, 
118 
surgeon's  orders  for,  109 
temperature  in,  104 
vomiting  in,  treatment,  98,  100 
peritonitis,  130 
symptoms,  130 
treatment,  130 
persistent  vomiting,  131 
phlebitis,  133 
symptoms,  133 
treatment,  134 
pneumonia,  131 
respiratoryfailure,  125 
causes,  125 
symptoms,  126 
treatment,  126 
shock,  121 
causes,  122 
prevention,  123 
symptoms,  123 
treatment,  124 
uremia,  130 
Poultice,  flaxseed,  165 

mustard,  165 
Powders,  dusting,  for  wounds,  140 
Preparation   for    operation    by    operating-room 
staff,  50 
of  bed  after  operation,  91-9S 
of  hands,  41.     See  also  Hand  sterilization. 
of  operative  field,  64 
baths  in,  61 
care  of  kidneys,  61 

of  stomach  and  bowels,  60 
of  teeth,  60 
constitutional,  58 
general,  58 

on  night  before  operation,  62 
preliminary  care,  59 
schedule  of  work,  63 
time  necessary  for,  59 
Private  house  operating  room,  anesthetist's  table 
for,  28 
arrangement,  23 
schematic,  22 
dismantling  after  operation,  36 
essentials  for,  20 
fumigation  of,  24 
laparotomy  kit  for,  30 
lighting  for,  20 
operating  table  for,  27 
preparation,  27 
Trendelenburg  position,  27 
preparation  of,  20,  21 


INDEX 


75 


Private  house  operating   room,  preparation  of, 
final,  26 
of  floor,  23 
setting-up,  26 
steps,  21-24 
requirements,  20 
screening  windows,  22 
setting-up,  29 
solutions  for,  32 
sterile  water  for,  25 
supplies  for,  32 
tables  for,  23 
utensils  for,  24 
Proctoclysis,  continuous  drop,   after  operation, 

103 
Prostration  in  appendicitis,  203 
Proud  flesh,  138 
Pulse  after  operation,  105 
in  appendicitis,  203 
recording,  157 

Relatives,  attitude  toward,  after  operation,  106 
Removal  of  sutures  by  surgeon,  117 
Respiration,  recording,  158 
Respiratory  failure,  post-operative,  125 

causes,  125 

symptoms,  126  ;;  . 

treatment,  126 
Rest,  recording,  161 

Restlessness,  treatment  of,  after  operation,  109 
Room,  requirements  of,  after  operation,  93 
Rubber  drains,  86 

gloves,  sterile,  changing  of,  57 

preparation  of,  for  use,  51-57 
supplies,  preparation  of,  172 

Salii-ie  enema,  169 

solution,  normal,  167 

fractional  sterilization,  26 
method  of  preparation,  25 
Salines  after  operation,  103 
Salt  block,  85 

Salts  and  glycerin  enema,  168 
Scalp  wounds,  dressing  of,  89 
Scar,  appendectomy,  satisfactory,  139 

tissue,  formation  of,  138 
Scars,  138 

degenerative  changes  in,  139 

hypersensitive,  139 

ventral  hernia  in,  139 
Scopolamin  and  morphin  anesthesia,  153 
Scrubbed  nurse,  29 

Scrubbing  hands,  41.     See  also  Hand  steriliza- 
■   tion. 


Scultetus  binder,  89 

Second  assistant  to  surgeon,  duties,  73 

intention,  healing  of  wounds  by,  137 
Sedative  enema,  170 
Septic  infection,  39 

common  forms  of  bacteria  in,  39 
methods  of  bacterial  invasion  in,  40 
of  prevention,  41 
Setting-up,  29 

Setting-up  private  house  operating  room,  30 
Sheets,  preparation  of,  175 
Shock  after  appendicitis  operation,  211 
post-operative,  121 
causes,  122 
prevention,  123 
symptoms,  123 
treatment,  124 
Silk  plaited  linen,  preparation  of,  171 
Silkworm-gut  drain,  86 

preparation  of,  172 
Singultus,  toxic,  post-operative,  131 
Sitting  up  after  operation,  soreness  from,  118 
Skull  operations,  position  for,  68 
Sleep,  recording,  161 
Slush  bath,  241-248 
Soaps  for  hand  sterilization,  42 
Soapsuds  enema,  170 
Soiled  dressings,  disposal  of,  149 
Solution,  saline,  fractional  sterilization,  26 

normal,  preparation,  25 
Soreness  from  sitting  up  after  operation,  118 
Spinal  anesthesia,  153 
Splint,  plaster-of -Paris,  183.     See    also    Plaster- 

of-Paris  splmt. 
Sponges,  gauze,  84 

keeping   account  of,  82 
uses  of,  82,  83 
Sputum,  method  of  disinfecting,  167 
Starch  enema,  170 
Sterile  cotton  gloves,  use  of,  57 
instruments,  table  of,.  33 
nurse,  29.     See  also  Nurse,  sterile. 
rubber  gloves,  changing  of,  57 

preparation  of,  for  use,  51-57 
supplies,  removing  from  package,   by  sterile 
nurse,  31 
method  of  opening,  by  unsterile  nurse,  31 
table  of,  32 
setting  up,  32 
water  for  private  house  operating  room,  25 
Sterilization,  fractional,  of  normal  saline  solu- 
tion, 26 
hand,  38.     See  also  Hand  sterilization. 
of  catheter,  198 


276 


INDEX 


Sterilization  of  instruments,  33 
after  operation,  35 
antiseptic  solutions  for,  34 
water  for,  33 

of  operative  field,  65 
Stimson-Weir  method  of  hand  sterilization,  48 
Stimulating  enema,  168 

method  of  administering,  169 
Stomach,  care  of,  before  operation,  60 
Strips,  preparation  of,  177 
Stupes,  turpentine,  165 
Sublimate-alcohol  method  of  hand  sterilization, 

48 
Supervisor,  surgical,  duties,  75 
Surgeon,  second  assistant,  duties,  73 

third  assistant,  duties,  73 
Surgeon's  clothing,  proper,  43 

face  mask,  217 

first  assistant,  duties,  72 

gown,  43 

hospital  kit,  178 

contents,  179,  180 
uses,  181 

orders  after  operation,  109 

portable  lamp,  20 
Surgical  leggings,  62 

materials,  preparation  of,  171 

nursing,  outline  of,  18 

supervisor,  duties,  75 
Suture,  catgut,  sizes,  82 

continuous,  80 

everting,  80 

Glover's,  80 

interrupted,  80 

Lembert,  81 

materials  for,  preparation,  171 

method  of  testing,  81 
'  removal  of,  by  surgeon,  117 

tension,  81 

Table,  anesthetist's,  28 

dining,  arrangement  of,  for  Trendelenburg 
position,  27 

for  private  house  operating  room,  23 

of  sterile  instruments,  33 

of  sterile  supplies,  32 
setting  up,  30 

operating.     See  Operating  table. 
Tableware,  method  of  disinfecting,  167 
Tampons,  preparation  of,  177 
Tapes,  abdominal,  untying,  114 

adhesive,  abdominal  pad  held  by,  88 
Teeth,  care  of,  before  operation,  60 
Temperature  after  operation,  104 


Temperature  in  appendicitis,  203 

recording,  157 
Tenderness  in  appendicitis,  203 
Tension  suture,  81 
Testing  suture,  method,  81 
Third  assistant  to  surgeon,  duties,  73 

intention,  healing  of  wounds  by,  138 
Thyroidectomy,  technic  of,  262-267 
Tincture  of  iodin,  165 
Tissue,  fibrous,  formation  of,  in  wounds,  137 

rubber,  preparing,  172 

scar,  formation  of,  138 
Toilet  of  patient  after  operation,  108 
Towels,  method  of  sterilizing,  167 

preparation  of,  175 
Toxic  singultus,  post-operative,  131 
Tray  for  catheterization,  112 
Trendelenburg  position,  68,  70 

arrangement  of  dining  table  for,  27 
on  operating  table  for  private  house  operat- 
ing room,  27 
Tub  bath  in  bed,  248-251 
Tubing,  rubber,  preparation  of,  172 
Turpentine  and  oil  enema,  169 

enema,  169 

stupes,  165 
Twisted  black  linen,  preparation  of,  171  ." 

Unsterile  nurse,  29.     See  also  Nurse,  unsterile. 
Uremia,  post-operative,  130 
Urine,  excretion  of,  recording,  161 
Utensils,  method  of  disinfecting,  167 

Vaginal  operations,  positions  for,  71 
Ventral  hernia  in  scars,  139 
Vomiting  after  operation  for  appendicitis,  211 
treatment,  98 
persistent,  post-operative,  131 

treatment,  133 
uncontrollable,  after  operation,  100 

Water,  administration  of,  after  operation,  100 

for  sterilization  of  instruments,  2,2> 

method  of  disinfecting,  167 

sterile,  for  private  house  operating  room,  25 
Weir-Stimson  method  of  hand  sterilization,  48 
Welch-Kelly  method  of  hand  sterihzation,  48 
Willard  Bartlett  method  of  preparing  catgut,  171 
Wounds,  136 

care  of,  140 

cleansing,  140 

coagulation  fibrin  in,  138 

draining,  141 
dressing,  141 


INDEX 


277 


Wounds,  dressing,  141 
recording,  162 
dusting  powders  for,  140 
exuberant  granulation  in,  138 
first  dressing,  140 
formation  of  fibrous  tissue  in,  137 
healing  by  first  intention,  136 
by  granulation,  137 
stimulation  of,  142 


Wounds,  healing  by  second  intention,  137 
by  third  intention,  138 
incised,  136 

infected,  treatment,  143 
methods  of  suturing,  80 
organization  in    137 

preventing  loss  of  drainage  material  in,  142 
recording  condition  of,  162 


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